Remote comprehensive eye examination system

ABSTRACT

An ophthalmic technician is present with a patient in an exam room to operate eye examination equipment and transmit patient information to remote location. At that remote location, a skilled technician is present to provide the necessary optical care, and may operate the phoropter from the remote location. Using video and/or teleconferencing equipment and a phoropter located in the patient examination room along with management software, the system works to determine the final optical prescription for the patient. That information, coupled with findings from other devices which are integrated with the management software, and that the patient uses locally, are reviewed by a remote-based optometrist or ophthalmologist.

RELATED APPLICATION

This application is a continuation of U.S. application Ser. No.15/916,639, filed Mar. 9, 2018, now pending, which is a continuation ofU.S. application Ser. No. 15/699,533, filed Sep. 8, 2017, now U.S. Pat.No. 9,980,644, which claims the benefit of U.S. Provisional PatentApplication Ser. No. 62/394,369 filed on Sep. 14, 2016, all of which areincorporated by reference.

FIELD OF THE DISCLOSURE

The present disclosure relates generally to an apparatus, method, andsystem for remote comprehensive eye examinations. This apparatus,method, and system may also be usefully configured to work in variousother arts beyond remote comprehensive eye examinations.

BACKGROUND

Comprehensive eye examinations need to become more accessible in theU.S., since over 75% of adults use some form of vision correction. Butmany areas have a limited supply of optometrists andophthalmologists—the gatekeepers for eye examinations—or such supply maybe reduced during certain days and hours of the week. Access tocomprehensive eye examinations is critical in determining not onlycorrective prescriptions for eyeglasses and contact lenses, but also inidentifying potential diseases of the eye and body, such glaucoma,macular degenerations, and hypertension.

The internet is being increasingly utilized for optical products such aseyeglasses and contact lenses. Further, there are new technologies thatoffer the consumer refractions via smartphones, portable devices, aswell as through the internet on a computer in order to determine thepatient's prescription. Companies and devices that currently offer thistechnology via refraction devices include: Opternative, Smart VisionLabs, Eyenetra, Peek, Pediavision, and 2win.

But these refraction-based systems do no provide the patient/consumerwith a comprehensive eye examination. While these systems update theirprescription for eyeglasses and/or contact lenses with a device, theyare not able to discover other potential ocular health issues. Indeed,the reduction of vision in the eye and therefore the necessity foreyeglasses and/or contact lenses is the stimulus that motivates apatient/consumer to see an eyecare professional. Thus, patients that usepresent-day internet-based tools for glasses or contacts will not beevaluated for other ocular-related medical issues and will not normallyschedule such visits with an optometrist or ophthalmologist. Withoutsuch visits, important ocular issues could be missed and go undiagnosed.Although extremely convenient, the use of these new technologies withoutproper medical guidance may results in adverse effects for patients, andultimately cause more harm than good.

Accordingly, it is therefore desirable to combine the convenience ofinternet or remote based eye testing with the availability of skilledoptometrists or ophthalmologists into an apparatus, method, and systemfor remote comprehensive eye examinations.

SUMMARY OF THE INVENTION

Embodiments of the present disclosure call for a remote station where anoptometrist or ophthalmologist need not be required to be on-site toperform a comprehensive eye examination. Instead, an ophthalmictechnician is present with the patient in the exam room to operate eyeexamination equipment and transmit patient information to remotelocation. At that remote location, a skilled technician is present toprovide the necessary optical and/or medical care, and may operate thephoropter from the remote location if he/she desires. Using video and/orteleconferencing equipment and a phoropter located in the patientexamination room along with management software, the system works todetermine the final optical prescription for the patient. Thatinformation, coupled with findings from other devices which areintegrated with the management software, and that the patient useslocally, are reviewed by a remote based optometrist or ophthalmologist.

While the patient is being evaluated for eyeglasses or contacts, theoptometrist or ophthalmologist may also operate the phoropter located inthe patient examination room from the remote location if he/she desiresand evaluate the patient for other ocular-related medical issues. Oncethe findings are finalized by the optometrist or ophthalmologistremotely, the final prescription for eyeglasses and/or contact lenses,along with any additional comments or findings, will print locally atthe examination location and be delivered to the patient.

The advantages of this remote station-based approach are widespread.

Patients benefit from the remote station because it provides them with amethod to obtain needed eye care at a time and location that isconvenient to them. Patients also benefit from the peace of mind that askilled optometrist or ophthalmologist will be evaluating them andchecking for ocular issues beyond the need for eyeglasses or contacts.

The optometrist or ophthalmologist benefits by being able to provide hisor her services at times and places of his or her choosing (not unlikethe way a driver works for ride-sharing services, such as Uber, at timesconvenient to him or her). Further, the potential pool of patients forthe optometrist or ophthalmologist is much larger since he or she is notlimited to the market of patients within driving distance of his or heroffice.

The host at the local side of the remote station, where patients arepresent, benefit because the services offered by the system allow forbetter utilization and synthesis of other parts of the host's business.For example, a retail optical store will often lose sales if a customerrequires a prescription to purchase eyeglasses and there is nooptometrist or ophthalmologist in the store to write the prescription.But it is impractical and expensive to have an optometrist orophthalmologist available during the many hours that a retail opticalstore needs to be open in order to make a profit. This is even more soin the case of an optical department for a large retailer, such asWalmart or Target, where the retailer may be open 18 to 24 hours perday. Hosting a remote station that provides access to an optometrist orophthalmologist at any needed time, day or night, significantly enhancesthe profitability of the optical store or optical department.

In addition, the present invention is designed to comply with therecommendations related to telemedicine as set forth by the AmericanOptometric Association (AOA). It is believed that no other prior systemmeets all such recommendations for comprehensive eye examinations thatinclude subjective refractions with professional judgement by a doctorfor an accurate objective refraction.

BRIEF DESCRIPTION OF THE FIGURES

The accompanying figures, where like reference numerals refer toidentical or functionally similar elements throughout the separateviews, together with the detailed description below, are incorporated inand form part of the specification, and serve to further illustrateembodiments of concepts that include the claimed invention, and explainvarious principles and advantages of those embodiments.

FIG. 1 (consisting of FIGS. 1A, 1B, 1C, 1D, 1E, 1F, 1G, 1H 1I, 1J, 1Kand 1L) is a system diagram of an apparatus, method, and system forremote comprehensive eye examinations, in accordance with someembodiments.

FIG. 2 is a flowchart showing the workflow of a local technician forremote comprehensive eye examinations, in accordance with someembodiments.

FIG. 3 is a machine interface screen for remote comprehensive eyeexaminations, in accordance with some embodiments.

FIG. 4 is a flowchart showing the workflow of a remote technician forremote comprehensive eye examinations, in accordance with someembodiments.

FIG. 5 is a the controller menu that may be used by the remote doctor toremotely operate a phoropter, in accordance with some embodiments.

FIG. 6 is a flowchart showing the workflow of a remote doctor for remotecomprehensive eye examinations, in accordance with some embodiments.

Skilled artisans will appreciate that elements in the figures areillustrated for simplicity and clarity and have not necessarily beendrawn to scale. For example, the dimensions of some of the elements inthe figures may be exaggerated relative to other elements to help toimprove understanding of embodiments of the present invention.

The apparatus and method components have been represented whereappropriate by conventional symbols in the drawings, showing only thosespecific details that are pertinent to understanding the embodiments ofthe present invention so as not to obscure the disclosure with detailsthat will be readily apparent to those of ordinary skill in the arthaving the benefit of the description herein.

DETAILED DESCRIPTION I. Compliance with Recommendations of the AmericanOptometric Association

A. Comprehensive Eye Examination Requirements

The present invention is designed to collect all of the information andperform all of these tests set forth by the AOA for a comprehensive eyehealth examination and vision analysis. Such requirements are set forthbelow.

1. Chief Complaint: assessment of the patient's reason for getting aneye exam.

2. General Physical Health History: complete health history to screenfor physical conditions and medications that may affect eyesight.

3. General Ocular Health History: complete eye health history includingfamily history of eye conditions, disease, or medication.

4. External and Internal Eye Health Evaluation: examination for thesigns of eye disorders, including cataracts and other eye disorders.

5. Current Prescription Analysis evaluation of current lensprescription, if applicable.

6. Visual Acuity: test for the eyes' ability to see sharply and clearlyat all distances.

7. Refraction: test for the eyes' ability to focus light rays properlyon the retina at distances and close by.

8. Tonometry: test to measure internal fluid pressure of the eye(increased pressure may be an early sign of glaucoma).

9. Visual Coordination: check for external eye muscle balance andcoordination.

10. Accommodative Ability: test of the eyes' ability to change focusfrom distance to near.

Prior telemedicine schemes have not been designed to accomplish all ofthe above tasks. Indeed, many provide only refractive services.

B. Optimal Platforms for Telemedicine

In addition to the above, the present invention is designed to complywith the recommendations of the AOA with respect to optimal telemedicinerequirement-live interactive eye and vision telehealth services. Per theAOA, “live interactive eye and vision telehealth services” are thosethat use videoconferencing as a core technology. Participants areseparated by distance, but interact in real-time. In contrast“store-and-forward” eye and vision telehealth services refers to amethod of providing asynchronous consultations to referring providers orpatients. A history and a set of images are collected at the point ofservice and are transmitted for review by an eye doctor. In turn, theeye doctor provides a consultative report back to the referring provideror patient at the point of service. “Eye and vision remote patientmonitoring services” refers to personal health and medical datacollected from an individual in one location via electroniccommunication technologies, which is transmitted to a provider in adifferent location for use in care coordination and related support.

The present invention is also designed to comply with therecommendations of the AOA for optimal uses of technology in synchronoustelehealth uses. Per the AOA, for synchronous telehealth uses, acontrolled environment, including adequate lighting, and a highresolution video camera is typically required at the originating site,and a monitor with resolution matched to the camera resolution isrequired at the distant site. Videoconferencing systems work optimallywhen a high-speed connection speed is used. Slower connection speeds maynecessitate that the individual presenting the patient perform eitherstill image capture or freeze frame to render a quality image. Forasynchronous uses, a controlled environment, including adequatelighting, and a digital camera with a high pixel resolution is typicallyrequired. For systems that transmit over the Internet, secure encryptionand multi-factor authentication are recommended. Remote patientmonitoring solutions often take the form of software as a service, withclinical software that allows eye doctors and other clinical staff tomanage patient populations by exception. Direct-to-patient eye andvision health-related applications, including online vision tests andother mobile eye and vision-related applications, must also comply withthe above requirements.

The present invention is designed to comply with the recommendations ofthe AOA regarding credentialing and privileging. Per the AOA, the JointCommission (TJC) has implemented standards for telehealth/telemedicine.Under the TJC telemedicine standards, practitioners who render careusing live interactive systems are subject to credentialing andprivileging at the distant site when providing direct care to thepatient. The originating site may use the credentialing and privileginginformation from the distant site when certain requirements are met.Doctors who render services using store-and-forward systems are viewedby TJC as “consultants” and might not be required to be credentialed atthe originating site. However, standards can vary by state andorganization.

The present invention is also designed to comply with therecommendations of the AOA regarding privacy and confidentiality. Perthe AOA, practitioners who provide eye and vision telehealth servicesshould ensure compliance with the Health Insurance Portability andAccountability Act of 1996 (HIPAA), as amended, and its implementingregulations. The handling of records, faxes, and communications issubject to the same HIPAA standards as those that apply in a standardoffice environment. For asynchronous telehealth uses, HIPAA compliancelargely relies on the originating site informing patients that theirinformation will be traveling by electronic means to another site forconsultation. This should be noted in the consent form at the point ofservice, and the HIPAA notice of privacy practices. In addition, allelectronic transmissions should be encrypted and reasonable care shouldbe taken to authenticate those providers who have electronic access tothe records.

The present invention is also designed to comply with therecommendations of the AOA regarding licensing. Per the AOA, interactivetelehealth requires the equivalent of direct patient contact. In theU.S., telehealth using interactive technologies is generally restrictedto jurisdictions where the eye doctor is permitted, by law, to practice.In other words, the provider using interactive technologies is typicallyrequired to be licensed to practice in the jurisdiction in which thepatient is located. For store-and-forward applications, most statesrequire telehealth providers to be licensed in the same state in whichthe patient resides, even when he or she acts only as a consultant.Doctors of optometry and other appropriate, licensed providers who wishto provide store-and-forward consultations across state lines shouldlimit such consultations to originating states in which they arepermitted, by law, to provide care.

The present invention is also designed to comply with therecommendations of the AOA with respect to responsibility/liability. Perthe AOA, if direct services (doctor-to-patient) are provided (noassistance at the referring site), the consulting eye doctor bears fullresponsibility (and potential liability) for the patient's care. Thediagnostic and therapeutic recommendations rendered are based solely oninformation provided by the patient. Therefore, any liability should bebased on the information available at the time the consult was answered.In a consultative modal (doctor-to-doctor), liability may be shared;however, the allocation of responsibilities will vary on a case-by-caseand state-by state basis. Doctors of optometry and other appropriate,licensed providers should verify that their liability insurance policycovers telehealth/telemedicine services, including those servicesprovided across state lines, if applicable, prior to the delivery of anysuch service.

C. Criteria for High-Quality Eye and Vision Telehealth Services

The AOA supports the use of eye and vision telehealth services providedby licensed eye doctors—doctors of optometry and ophthalmologists—andother appropriate, licensed professionals in certain instances, andsupports coverage of and payment for eye and vision telehealth services,when several important criteria are met. The present invention isdesigned to meet certain of the AOA's criteria as set forth below.

1. The standard of care must remain the same regardless of whether eyeand vision telehealth services are provided in-person, remotely viatelehealth, or through any combination thereof. Doctors may not waivethis obligation, or require patients to waive their right to receive thestandard of care. Further, a payor may not require either the doctor orpatient waive the right to receive the standard of care.

2. The use of eye and vision telehealth services may be appropriate forstandard basic data acquisition, gathering repetitive specific data,confirmation of expected therapeutic results, confirmation ofstability/or homeostasis, and notifications of changes in chronicconditions. Further uses may be appropriate as new evidence andtechnologies are made available.

3. The use of eye and vision telehealth services is not appropriate forestablishing the doctor-patient relationship, for an initial diagnosis,as a replacement for recommended face-to-face interactions, or as areplacement for partial or entire categories of care.

4. Eye doctors and other licensed professionals delivering eye andvision telehealth services must be licensed in the state in which thepatient receives services (subject to respective laws and regulations),and must abide by that state's licensure laws and regulations.

5. Patients must be made aware of potential limitations of the servicesthat can be provided via telehealth. Eye doctors or other licensedprofessionals delivering eye and vision telehealth services must, whenclinically appropriate, promptly refer patients for an in-persondiagnosis and/or care

6. Patients or referring practitioners seeking eye and vision telehealthservices must have a choice of eye doctor, if possible, and must haveaccess, in advance, to the licensure and qualifications of the clinicianproviding services. The delivery of eye and vision telehealth servicesmust be consistent with state scope of practice laws in the state inwhich the patient is located at the time of the encounter.

7. The patient's relevant health history must be collected as part ofthe provision of eye and vision telehealth services. Appropriate healthrecords should be available to the consulting eye doctor prior to or atthe time of the telehealth encounter. Consulting eye doctors should havea good understanding of the culture, health care infrastructure, andpatient resources available at the site from which consults areoriginating. The provision of eye and vision telehealth services must beproperly documented. These health records should, when appropriate, beavailable at the consultant site and at the referral site.

8. The provision of eye and vision telehealth services should includecare coordination with the patient's primary care provider, and eyedoctor, if one exists. This coordination should include, at a minimum,identifying the patient's primary care provider and eye doctor in theeye and vision telehealth services referral record, and providing a copyof the health record to those members of the treatment team who do nothave electronic access to it. This provision is especially important sothat information regarding diagnoses, test results, and medicationchanges are available to the care team.

9. Organizations and clinicians participating in eye and visiontelehealth services should have an ongoing training program and currentlist of required criteria for both the distant and receiving sites. Inaddition, those programs that are using eye and vision telehealthservices should have documentation of their training programs for anytechnician who is capturing clinical images and for any clinician who isproviding consults. Each organization should also maintain documentationon how the program protects patient privacy, promotes high-qualityclinical and image data, continuity of care, and care coordination forpatients who may request or require subsequent in-person evaluations orprocedures.

10. While monitoring patients remotely, the regular interaction betweenclinical care coordination staff, patients, and their eye doctor(s) andother primary care providers is critically important for successfuloutcomes. Only FDA-approved devices being utilized in the manner forwhich they were approved may be used to monitor patients remotely. Therisks and benefits of medical devices should be properly and thoroughlyweighed through science and evidence to ensure efficacy and quality andto protect the public health.

11. Organizations and clinicians participating in eye and visiontelehealth services must have protocols for local referrals (in thepatient's geographic area) for urgent and emergency services. Mechanismsto facilitate continuity of care, follow-up care, and referrals forurgent and emergency services in the patient's geographic area must bein place. Any new prescriptions must be communicated directly to thepatient's care team (unless the team has easy electronic access to theeye and vision telehealth record).

12. When creating directories of participating eye doctors forestablishing network adequacy, an insurer may not consider access to eyeand vision telehealth services as a substitute for locally availabledoctors of optometry, who can offer a wide range of eye health andvision care services.

13. The AOA supports eye and vision telehealth services designed anddedicated to provide demonstrably high-quality patient care. The AOAdoes not support eye and vision telehealth services primarily focused onoffering access to prescriptions without conducting an adequate history,examination, patient diagnosis, and/or valid and proper doctor-patientrelationship.

14 With respect to the doctor-patient relationship:

(a) For eye and vision telehealth services where a referring providerultimately manages the patient (including prescriptions), the consultingeye doctor is not required to have a pre-existing, valid doctor-patientrelationship. It is optimal, however, if the patient has availableaccess to in-person follow-up with a local eye doctor when needed.

(b) For live interactive eye and vision telehealth services anddirect-to-patient eye and vision health-related applications, includingonline vision tests and other mobile eye and vision-relatedapplications, the consulting eye doctor must either: (i) Have anexisting doctor-patient relationship (having previously seen the patientin-person); or (ii) Before providing services, establish communicationwith the patient's existing care team, including the patient's eyedoctor, in order to document eye, vision, and systemic history, pastcomprehensive eye and other examinations, and any related patientdiagnosis; or (iii) Be a part of an integrated health delivery systemwhere the patient already receives care, in which the consulting eyedoctor has access to the patient's existing medical record and cancoordinate follow-up care.

15. The use of direct-to-patient eye and vision-related applications,including online vision tests and other mobile eye and vision-relatedapplications, raise several additional issues (and all of the abovecriteria still apply):

(a) Direct-to-patient eye and vision-related applications, based oncurrent technologies and uses, cannot replace or replicate in-personcomprehensive eye examination provided in-person by an eye doctor.

(b) The eye health portion of a comprehensive eye examination and therefractive portion of a comprehensive eye exam, based on currenttechnologies and uses, cannot be replaced or replicated bydirect-to-patient eye and vision-related applications.

(c) Screening for specific or groups of eye health issues usingtelehealth for direct-to-patient eye and vision-related applications,based on current technologies and uses, should not be used to diagnoseeye health conditions or as a replacement or replication for acomprehensive dilated eye exam. Screenings solely identify risk, whichis a risk that only an in-person comprehensive eye examination can beginto valuate, mitigate, and/or address.

(d) Refractive tests, including online vision tests and other mobilevision-related applications, cannot be, based on current technologiesand uses, used to provide a refractive diagnosis and/or an eyeglass orcontact lens prescription, due, in part, to these tests not currentlyincluding a controlled testing environment, subjective refraction, orprofessional judgement. Additionally, self-administered vision tests,based on current technologies and uses, cannot be relied on as accuratefor an objective refraction.

(e) Photographs obtained by patients, their family members, or theirfriends outside of a clinical setting may not be of adequate quality, ormay not include the information needed to make an accurate diagnosis.

II. Workflow for Remote Comprehensive Eye Examination

Turning to FIG. 1, shown is an overall system workflow diagram for anapparatus, method, and system for remote comprehensive eye examinations.Shown are workflows for the exam site 1100, central server (exam siteand remote technician connection) 1200, remote technician 1300, remotedoctor 1400, and central server (remote doctor connection) 1500.

The exam site workflow 1100 may initiate a connection to the centralserver (exam site and remote technician connection) 1200 on a specifiedport and wait for a response 1101. Similarly, the remote technician 1300may initiate a connection to the central server (exam site and remotetechnician connection) 1200 on a specified port and wait for a response1301. In both of these cases, the central server (exam site and remotetechnician connections) 1200 may also be listening for connections onspecified ports from exam sites and remote technicians 1201, which maybe different ports for exam sites and remote technicians. In the case ofthe exam site initiated connection, the central server (exam site andremote technician connection) 1200 may send a new port number back tothe initiating exam site 1100 to use for the connection 1202. The examsite 1100 may receive this new port number from the central server (examsite and remote technician connection) 1200 and disconnect from theoriginal port number 1102. Now, the exam site 1100 may initiate a newconnection to the central server (exam site and remote technicianconnection) 1200 using the new port provided by the central server (examsite and remote technician connection) 1200 and using an exam user IDand password 1103. The central server (exam site and remote technicianconnection) 1200 may detect the new connection from the exam site 1100over the updated port number and checks the IP address. If the IPaddress is the same as original exam site 1100 IP address, then theconnection may be kept open. If the IP address is different, then theconnection may be closed 1204. If the IP address is the same, and theconnection is kept open, then the central server (exam site and remotetechnician connection) 1200 may verify the exam user ID and password. Ifthe credentials don't match an existing account, then the connection maybe closed. If the credentials do match an existing account, thenconnection may be kept open 1206.

Similar to the case with the exam site, if the central server (exam siteand remote technician connection) 1200 receives a connection from theremote technician 1300, the central server (exam site and remotetechnician connection) 1200 may send a new port number to the initiatingremote technician 1300 to use for the connection 1203. The remotetechnician 1300 may receive this new port number from the central server(exam site and remote technician connection) 1200 and disconnect fromthe original port number 1302. Now, the remote technician 1300 mayinitiate a new connection to the central server (exam site and remotetechnician connection) 1200 using the new port provided by the centralserver (exam site and remote technician connection) 1200 and using anremote user ID and password 1303. The central server (exam site andremote technician connection) 1200 may detect the new connection fromthe remote technician 1300 over the updated port number and checks theIP address. If the IP address is the same as original remote technician1300 IP address, then the connection may be kept open. If the IP addressis different, then the connection may be closed 1205. If the IP addressis the same, and the connection is kept open, then the central server(exam site and remote technician connection) 1200 may verify the remoteuser ID and password. If the credentials don't match an existingaccount, then the connection may be closed. If the credentials do matchan existing account, then connection may be kept open 1207.

Once the remote user and site has been verified, the central server(exam site and remote technician connection) 1200 may send an updatedlist of remote technicians 1208 currently available to the exam site1100. The exam site 1100 technician may be informed if there are anytechnicians currently available 1104.

At the exam site 1100, the patient may fill out their history and otherinformation on a tablet PC or other medium, and that information 1105may be sent to the central server (exam site and remote technicianconnection) 1200. The central server (exam site and remote technicianconnection) 1200 receives this patient information, and the patient maybe added to the list of patients currently waiting for an eye exam. Thepatient list and history information for each patient may be sent to theremote technician 1300 and the approximate wait time 1209 may be sent tothe exam site 1100. At the exam site 1100, the selected patient and/ortechnician are informed of an approximate wait time 1106. At the remotetechnician 1300, the next patient waiting for an exam may be displayed,and patient history may be reviewed by the technician 1304. When theremote technician 1300 is ready, they may send a signal to the centralserver (exam site and remote technician connection) 1200 indicating thatthey may be ready to start the exam 1305. At the central server (examsite and remote technician connection) 1200, the patient may be movedoff the waiting list, and the exam site 1100 may be informed that theexamination may now begin for the selected patient 1210. At the examsite 1100, the patient and/or technician may be informed that the examis about to begin 1107. At the remote technician site 1300, the remotetechnician may select a predefined set of tasks for the exam or they maycreate a custom list of tasks that may be based on the patient'shistory. Verbal instructions may also be provided once the video link isestablished if available. Whenever possible, the required tasks may beautomated 1306 at the exam site 1100. At the central server (exam siteand remote technician connection) 1200, the video conference may link1211, 1212 the remote technician 1300 and exam site 1100. At the examsite 1100, the patient and/or technician is informed that the exam maybe ready to begin 1108. Video conference data may flow between the examsite 1100 and remote technician 1300 through the central server (examsite and remote technician connection) 1200. The task listed selected bythe remote technician 1300 may be sent 1307 through the central server(exam site and remote technician connection) 1200 to the exam site 1100.The central server (exam site and remote technician connection) 1200relays 1213 this information to the exam site 1100. At the exam site1100, the requested task may be presented to the local technician 1109.The requested tasks may be performed and results may be sent to theremote technician 1300 at each point where a reported flag has beeninserted or at the end of the task list if no report flags are present1111. During this phase, the system may interact 1110 with equipment atthe exam site 1100. The central server (exam site and remote technicianconnection) 1200 receives information and relays 1214 it to the remotetechnician 1300. The remote technician 1300 may receive they results ofthe tusks performed so far and may review the results 1308. If the taskis a remote refraction, the remote technician 1300 may remotely controlthe phoropter using the manufacturer's user interface 1309. At the examsite 1100, the remote phoropter may be controlled by the remotetechnician 1300 using the manufacturer's user interface 1112.Alternatively, the remote technician 1300 may modify the list ofremaining tasks and return a revised list back to the central server(exam site and remote technician connection) 1200 if desired 1310. Thisrevised task list may be sent to the exam site 1100 through 1307 thecentral server (exam site and remote technician connection) 1200. Duringthe remote phoropter exam, the remote technician 1300 may control thespecific eye charts or patterns that are displayed to the patient duringthe refraction 1311. The central server (exam site and remote technicianconnection) 1200 relays this control information 1215 to the exam site1100. At the exam site 1100, eye charts used during the exams may beremotely controlled by the remote technician 1300 or by the localtechnician 1113.

At the conclusion of the exam, the central server (exam site and remotetechnician connection) 1200 is passed all of the information collectedto this point and is informed that the remote technician 1300 portion ofthe eye exam is complete 1312. The final information from the remotetechnician 1300 is received by the central server (exam site and remotetechnician connection) 1200 and the exam site 1100 may be informed thatthe exam is complete. All exam results to this point 1216 may be storedon the central server (exam site and remote technician connection) 1200.At the exam site 1100, the exam is completed, and the video conferencelink may be disconnected and instructions may be displayed to wait forthe doctor to issue the final prescription 1115. The video conferencelink may be disconnected 1114 and the exam site 1100 is informed ifthere are any remote technicians 1300 currently available for anothersession 1104. At the remote location 1300, the video conference link mayend 1313. The remote technician 1300 may choose to examine more patientsat this point, or they may disconnect 1314. If they choose to examinemore patients, they may be informed of the next patient waiting for anexam by central server (exam site and remote technician connections)1200 and patient history can be reviewed by remote technician 1300 1304.

The remote doctor 1400 may initiate a connection to the central server(doctor connection) 1500 on a specified port and wait for a response1401. The central server (doctor connection) 1500 may also be listeningfor connections 1501 on specified ports from remote doctors 1400. Thecentral server (doctor connection) 1500 may send a new port number backto the initiating remote doctor 1400 to use for the connection 1502. Theremote doctor 1400 may receive this new port number from the centralserver (doctor connection) 1500 and disconnect from the original portnumber 1402. Now, the remote doctor 1400 may initiate a new connectionto the central server (doctor connection) 1500 using the new portprovided by the central server (doctor connection) 1500 and using a userID and password 1403. The central server (doctor connection) 1500 maydetect the new connection from the remote doctor 1400 over the updatedport number and checks the IP address. If the IP address is the same asoriginal remote doctor 1400 IP address, then the connection may be keptopen. If the IP address is different, then the connection may be closed1503. If the IP address is the same, and the connection is kept open,then the central server (doctor connection) 1500 may verify the user IDand password. If the credentials don't match an existing account, thenthe connection may be closed. If the credentials do match an existingaccount, then connection may be kept open 1504. The central server(doctor connection) 1500 may then add the remote doctor 1400 to the listof doctors currently online 1505. At the remote doctor 1400, once theconnection is established and verified by the central server (doctorconnection) 1500, the software may go into a wait state 1404 untilsomething is received from the central server (doctor connection) 1500.The remote doctor 1400 may indicate that they are ready to see the nextpatient 1405. The central server (doctor connection) 1500 may receive asignal that the remote doctor 1400 is ready to review their next patient1506. All patient history and exam information for the next patientwaiting for their final prescription is sent 1507 to the remote doctor1400 by the central server (doctor connection) 1500. The remote doctor1400 may receive the patient information from the central server (doctorconnection) 1500 for review 1406.

At the central server (exam site and remote technician connections)1200, the list of doctors currently logged into the system may bescanned using a set of rules. The appropriate doctor may be alerted andall patient information may be sent to the remote doctor 1400 for reviewif they are signed into the system. If they are not signed into thesystem, a text message or similar medium may be sent 1217. The remotedoctor 1400 may be alerted that patient information has been receivedand is waiting for review 1407. The remote doctor 1400 may review thepatient history and exam information and may determine the finalprescription. The prescription, along with any special instructionsand/or referral information is sent to the central server (exam site andremote technician connections) 1200, which is then passed on to the examsite 1100. The remote doctor's 1400 signature or other authorization mayalso be included 1408. The central server (exam site and remotetechnician connections) 1200 receives this information 1218, and relaysit to the exam site 1100. The exam site 1100 may be notified when theprescriptions and/or any special instructions are received from theremote doctor 1400 through the central server (exam site and remotetechnician connections) 1200 so that the local technician may benotified 1116. The final prescription and/or any special instructionsmay be printed locally along with the doctor's signature or otherauthorization and presented to the patient 1117. The patient mayacknowledge receiving the prescription and/or recommendations 1118. Theremote doctor 1400 may be informed through the central server (exam siteand remote technician connections) 1200 that the prescription and/orspecial instructions have been understood and accepted 1219. The remotedoctor 1400 may receive this confirmation of reception and understandingof prescription and information, and concludes the eye exam 1409. Theremote doctor 1400 may choose to disconnect at this time, or they maycontinue to see more patients 1410. If they decide to see more patientsthey may indicate that they are ready to see the next patient 1405. Atthe exam site 1100, if the exam site has electronic medical records(EMR), all patient and exam information may be uploaded to the EMR 1119.Product marketing material may be introduced to the patient at this timebased on a set of rules determined by the doctor 1120.

III. Features of Remote Comprehensive Eye Examination

The potential features of the remote comprehensive eye examinationapparatus, method, and system are listed below. Any or all of thesefeatures may be used in various combinations.

A. Server Features

1. Configuration and Setup Menu

The configuration and setup menu may have the following features:

a. The server Configuration/Maintenance/Setup menu(s) will be user andpassword protected.

b. Enter, edit, and delete all info and passwords for exam sites, remotetechnicians, and remote doctors.

c. Enter, edit, and delete pricing groups that can be assigned to anyuser or groups of users.

d. Create and edit rules based on things such as groups, insurance, examsite, remote technician and doctor location.

e. Record all exam activity (Exams started, exams completed, who didwhat, how long it took, etc.).

f. Set and edit exam fees linked to specific groups.

g. Set and edit exam fees for each individual location that is notassigned to a group or insurance carrier.

h. Allow optional volume discounts to a specific user or group

i. Automatically produce reports and statements at a given interval oron request.

j. Automatically email reports and statements at a given interval or onrequest.

k. Allow high level user to add adjustments to any statement.

2. Connection and Storage.

a. Implement all server logic as defined in the flowchart.

b. Initial connection and handshake with port info to exam site, remotetechnician, and remote doctor software.

c. User ID, password, and IP verification on every final connection.

d. Handle multiple simultaneous connections from exam sites, remotetechnicians, and remote doctors.

e. Handle multiple simultaneous communication links between specificexam sites, remote technicians, and doctors.

f. Logic to pair the most appropriate remote technician and/or doctorwith the patient based on rules.

g. Transmission encryption.

h. Disk storage encryption.

i. Video conferencing software will be used for the video link.

3. Communication

a. Send pass-through commands from the remote technician to the examsite to control an interfaced phoropter for the refraction (May not beneeded if the digitally controlled phoropter comes with its own remoteinterface from the manufacturer).

b. Send pass-through commands from the remote technician to the examsite to control an interfaced eye chart.

c. Maintain a current list of all exam sites currently connected

d. Maintain a current list of all remote technicians currentlyconnected.

e. Maintain a current list of all remote doctors currently connected.

f. Send a current list of connected exam sites to the remote technicianwhen requested.

g. Send a current list of connected remote technicians to the exam sitewhen requested.

h. Send a current list of connected remote doctors to the remotetechnician when requested.

i. Send a current list of connected remote doctors to the exam site whenrequested.

j. Send a current list of remote doctors not connected but marked asavailable to the exam site when requested.

k. Send a current list of remote doctors NOT connected but marked asavailable to the remote technician when requested.

l. Send a text alert to a remote doctor that is not connected but markedas available.

m. Relay information from the exam site to the remote technician asneeded, perhaps using a Digital Imaging and Communications in Medicine(DICOM) protocol.

n. Relay information from the remote technician to the exam site asneeded, perhaps using a DICOM protocol.

o. Relay information from the remote technician to the remote doctor asneeded, perhaps using a DICOM protocol

p. Relay information from the remote doctor to the exam site as needed,perhaps using a DICOM protocol.

q. Relay information from the exam site to the remote doctor as needed,perhaps using a DICOM protocol.

r. Accept and act on supported server commands from the exam site.

s. Accept and act on supported server commands from the remotetechnician.

t. Accept and act on supported server commands from the remote doctor.

u. Send pass-through commands on to the intended recipient (exam site,remote technician, or remote doctor).

v. Send an estimate the time remaining before a particular patient'sexam can begin based on previous exam completion times.

w. DICOM protocol to be used if possible to relay information betweenthe exam site, remote technician, and remote doctor. Some examples ofwhat this may include are:

i. Visual acuity (without glasses, with current glasses, with new Rx,etc.).

ii. Current glasses prescription.

iii. Patient information and history.

iv. Results from equipment interfaced at the exam site.

v. Keratometer readings (K readings).

vi. Cornea Topography.

vii. Autorefractor readings (Rx).

viii. Fundus photography (photos).

ix. Slit lamp (may be photos or video).

x. Manual or interfaced Phoropter results (Rx).

xi. Other interfaced Equipment.

xii. Other objective test results.

xiii. Other subjective test results.

B. Exam Site Development

1. Configuration and Setup Menu

a. The exam site software will need to have a password protectedsetup/configuration menu.

b. Enter, edit, or delete all exam site users and passwords

c. Enter and edit server IP and server connection port.

d. Enter and edit ID and password to use for server login.

e. Define the interfaced machines that are available at the exam siteand define their function(s).

f. Define the manual operated machines that are available at the examsite and define their function(s).

g. Enter, edit, or delete rules that determine what if any products willbe presented and recommended after the exam is finished.

h. Setup will need an option to allow exporting the cumulative examresults when the exam is completed to a specific EMR.

i. Have an option to assign the preferred remote technician for examswhen available.

2. Connections and Storage

a. Implement all server logic as defined in the flowchart.

b. Initial connection and handshake and receive the reconnect port infofrom the main server.

c. Reconnect on the specified port for the final connection with theserver.

d. Send the exam site's user ID and password for login.

e. Transmission encryption.

f. Disk storage encryption.

g. Video conferencing software may be used for the video link.

3. User Interface (May be a Dual-Monitor System)

a. Monitor A will be used for accessing the setup menu and forinteraction as needed with the exam site technician.

b. A second monitor may be optionally used for interaction as neededwith the exam site patient.

c. Note that separate software may be used on a tablet at the exam siteto collect information from the patient prior to the exam

4. Communications

a. Retrieve the collected patient information from the tablet computerover the local area network.

b. Send patient information and history to the remote technician.

c. Send supported server commands to the set ver and wait for aresponse.

d. Send supported remote technician commands through the server and waitfor a response.

e. Send supported remote doctor commands through the server and wait fora response (“Rx accepted” is one).

f. Receive commands from the server and act on the command appropriately(“Task list” is one).

g. Note that if the phoropter at the exam site does not come with aremote interface from the manufacturer, an interface between the remotetechnician and the machine will have to be developed.

h. Note that if there is a need for the remote technician to control theeye chart at the exam site during the refraction, an interface betweenthe remote technician and the eye chart device will have to bedeveloped. Equipment interface commands from the server will need to bepassed through to the intended equipment.

i. Receive the final Rx from the doctor through the server and print itlocally. It will contain the doctor's signature along with any specialinstructions or recommendations.

j. After the final Rx is received and the exam is done, the system willlook at any and all rules that are present regarding product promotionand will then present the appropriate product info (if any) to thepatient.

C. Remote Technician Site Development

1. Configuration and Setup Menu

a. Each technician will have their own copy of this software and it willbe installed on a separate computer or separate folder on the samecomputer so there will be no need to handle multiple technicians andmultiple passwords in this software.

b. The remote technician software will need to have a password protectedsetup/configuration menu.

c. Enter, edit, or delete the remote technician's info.

d. Enter and edit the server IP and server connection port.

e. Enter and edit ID and password to use for the server login for thisremote technician.

f. Enter, edit, or delete tasks that the technician can choose from ifthey need to design a custom list of exam tasks for a specific patient.This list should be stored in a separate file that can be easily copiedto another technician's computer.

g. Define one or more named lists of pre-set tasks the technicians canchoose from when doing the examination. Each item in the named list willbe placed in the list in the same order it will need to be performedduring the actual eye exam.

h. Have an option to enter, edit, or delete a list of preferred remotedoctors to choose from and notify if available when the techniciancompletes the exam.

i. Have an option to enter, edit, or delete a list of exam locationsthat the technician is limited to when doing a remote exam. A checkboxfor “No Limit” or “Allow All” should also be available that would allowthe technician to do an exam at any exam site that has specified thatthis technician can do their exams.

j. Setup configuration may be needed for any remotely interfaced examequipment such as a remotely controlled phoropter or eye chart.

2. Connections and Storage

a. Implement all remote technician logic as defined in the flowchart.

b. Initial connection and handshake and receive the reconnect port infofrom the main server.

c. Reconnect on the specified port for the final connection with theserver.

d. Send the remote technician's user ID and password for login.

e. Transmission encryption.

f. Disk storage encryption.

g. Video conferencing software will be used for the video link, but itis unclear if or how it will need to be interfaced.

3. User Interface (May be a Dual-Monitor System).

a. The menu system will contain a user interface that allows thetechnician to perform all tasks as defined in the flowchart.

b. The menu system will allow the remote technician to view and selectfrom a list of patients currently waiting for an eye exam.

c. The menu system will allow the remote technician to view the patientinfo and history for any patient in their selection list prior toselecting a patient and starting an exam.

d. The menu system will allow the remote technician to choose from anamed list of pre-set tasks to use when doing the exam, or they maydesign a custom list using the list of tasks that have been created inthe setup menu.

e. Depending on how the video conferencing software in integrated withthis system, the video conferencing software may be started from thetechnicians menu

f. When the exam site has finished all tasks and the remote refractionis complete, all information collected so far about the patient and fromall equipment is sent through the server to the remote technician whereit can be viewed in a menu system. The remote technician may either besent any of the photos and/or video that may be collected during theexam, or just the values collected from each task. The doctor receiveseverything.

g. The menu system needs an option that allows the remote technician totell the exam site that the exam is complete and ready to go to thedoctor for final Rx. The remote technician should be allowed to addtheir own comment to the signal and this comment will be added to thetotal data collected at the exam site.

h. The menu needs an option to terminate the exam and to specify areason.

4. Communications

a. Send supported server commands to the server and wait for a response.

b. Send supported remote technician commands through the server to theexam site and wait for a response.

c. Receive supported commands from the server and act on the commandappropriately.

d. Receive supported data from the exam site through the server and acton the info appropriately.

e. Pass remotely interfaced equipment commands to the exam site throughthe server.

f. Support for all communications related items defined in the flowchartthat are not covered.

D. Remote Doctor Development

1. Configuration and Setup Menu

a. Each doctor will have their own copy of this software and it will beinstalled on a separate computer or separate folder on the same computerso there will be no need to handle multiple doctors and multiplepasswords in this software module.

b. The remote doctor software will have a password protectedsetup/configuration menu.

c. Enter, edit, or delete the remote doctor's information.

d. Enter and edit the server IP and server connection port.

e. Enter and edit ID and password to use for the server login for thisremote doctor.

f. Allow entering all doctor information (name address, license,business name, contact phone numbers, email, text #, etc.).

g. Allow storing a digital copy of the doctor's signature.

h. Allow doctor to specify if they want to be alerted via text if andwhen they are not online and an Rx is waiting to be finalized by them.

i. Have an option to enter, edit, or delete a list of exam locationsthat the doctor will be limited to when finalizing an Rx. A checkbox for“No Limit” or “Allow All” should also be available that would allow thedoctor to finalize an Rx at any exam site that has specified that thisdoctor can finalize their exams.

2. Connection and Storage

a. Implement all remote doctor logic as defined in the flowchart, above.

b. Initial connection and handshake and receive the reconnect portinformation from the main server.

c. Reconnect on the specified port for the final connection with theserver.

d. Send the remote doctor's user ID and password for login.

e. Transmission encryption.

f. Disk storage encryption.

3. User Interface (May be a Dual-Monitor System).

a. The menu system will contain a user interface that allows the remotedoctor to perform all tasks as defined in the flowchart, above.

b. Receive and display an alert of some kind if at least one Rx iswaiting for this doctor's approval.

c. The menu system will allow the remote doctor to view and select froma list of patients currently waiting to have their Rx finalized.

d. The menu system will allow the remote doctor to view the patient infoand history for any patient in their selection list prior to selecting apatient and starting the process of finalizing the Rx.

e. The selected patient's info, history, and all data collected duringthe exam should be available to view from the menu system. Theinformation collected will include values collected during each examtask, but it may also include photos and video which should also beviewable from the menu system.

f. When the doctor has reviewed all the available information, they willmake a determination about what the final Rx should be. The menu systemneeds to have a way for the doctor to enter the final Rx info along withany comments, recommendations, or special instructions they might wantto pass on to the patient. If the doctor sees a condition that needs areferral, they may decide not to issue an Rx and to simply send referralinfo in the special instructions.

g. There is a button to allow sending everything needed to print thefinal Rx at the exam site. This includes the doctor's name, businessname, address, phone, possibly email, state license number, final Rx,instructions, and a digital copy of the doctor's signature.

4. Communications

a. Send supported server commands to the server and wait for a response.

b. Send supported exam site commands through the server to the exam siteand wait for a response.

c. Receive supported commands from the server and act on the commandappropriately.

d. Receive supported data/commands from the exam site through the serverand act on the info appropriately.

e. Support for all communications related items defined in the flowchartthat are not covered above.

IV. System Operations

The following provides a comprehensive description of role of eachparticipant in the apparatus, method, and system for remotecomprehensive eye examinations: the patient, the local technician, theremote technician and the remote doctor. The patient may be assigned toa local eyecare technician, where the patient and the local eyecaretechnician are located at a local diagnostic center. The patient is thenassigned to a remote eyecare technician (possibly by the localtechnician), where the remote eyecare technician is located at a firstremote diagnostic center. The patient is finally assigned (possibly bythe local technician) to a eyecare doctor, where the eyecare doctor islocated at a second remote diagnostic center, which may or may not bethe same remote diagnostic center as the first remote diagnostic center.Thus, in some embodiments, the eyecare doctor, the remote technician andthe local technicians are in different locations.

A. The Patient

The patient portal and kiosk is a hand-held tablet computer with customsoftware that is used by the patient during the examination process.This tablet can be used to update the patient medical history, view thecurrent exam status, and also view previous prescriptions. The tabletwill also provide links to various websites and videos which can be usedto educate and entertain the patient while in the waiting area.

1. New Patient

When a new patient arrives at the doctor's office, the local technicianwill need to begin the process of gathering information about thatpatient to properly complete the examination. A vital step in thisprocess is providing a kiosk tablet to the patient for them to fill outforms requesting patient information.

The local technician needs to start the process on the kiosk tablet ofadding a new patient.

The local technician will need to click “Add Patient” to start theprocessing of adding a new patient into the system. When this button isclicked, the local technician Login Details dialog is displayed.

In this dialog, the technician will enter their username and password,which is also used to login to the patient portal. After thisinformation has been properly entered, the kiosk tablet will present apage requesting patient information. It is at this point that thetechnician would hand the tablet off to the patient, asking the patientto fill-in the online forms.

The following images display the form that the patient will fill-out onthe kiosk tablet. This form contains information such as name, address,birthdate, insurance information, signature, etc. Also, this form willallow the viewing of the Terms and Conditions and Privacy Policy, forthe patient's approval.

After the patient completes filling in the patient information andclicks the “Submit” button, the patient will be shown the login screen,where they can login to the patient dashboard. Details of the patientdashboard are contained in the following section.

2. Existing Patient

The patient will login to the patient portal, by filling in theirusername and password on the dialog as illustrated in the followingimage.

When the patient logs into the system for the first time, they will bepresented with the following dialog, where they will need to agree tothe Terms and Conditions and Privacy Policy to continue using thepatient portal.

At this point, the patient is now logged into the patient portal. Fromthe patient portal, the patient can view the current exam status, reviewprevious prescriptions, update personal information (address, phonenumber, etc), and update their medical history, among other items.

When the patient logs into the patient portal, the patient dashboardwill be presented. The dashboard contains information about the currentexam status for the patient. The following shows the dashboard, with nopatients currently waiting for an examination.

There are 4 main sections to the patient dashboard. As the patient movesthrough each phase of the examination process, the appropriate sectionsof the dashboard will be updated. From this dashboard, the patient canview the status of various aspects of the examination.

Before the examination, the patient should update their medical history,by selecting the “Add Medical History” button along the left-hand sideof the screen. This will display the following form, which asks variousquestions about the patient's medical history.

3. Local Technician Status

When an examination is starting for the patient, the dashboard willchange to display data similar to the following screen capture. Thestatus is displayed as waiting for the local technician exam to begin.

Once the local technician has begun the exam process, the status on thepatient dashboard will be updated accordingly. In the following image,the patient's status has been updated to local technician exam inprogress, indicating that the patient is currently being examined by thelocal technician.

After the local technician's examination has completed, the patient willbe passed to the remote technician. While the remote technician isperforming the refraction, the patient's dashboard will be updated witha status indicating that the remote technician exam is in progress. Thedashboard will update to reflect the current status when the remotetechnician exam has completed, and the patient is waiting for the remotedoctor.

While the doctor is examining the patient, the dashboard is updated toreflect this status. When the exam has been completed, the patientdashboard will reflect the status.

4. Other Features

After one or more examinations have been completed on the patient, theycan use the “View Prescription” button to view the current and anyprevious prescriptions.

The update profile option will allow the patient to change personalinformation, including such items as address, employer, insurance, etc.The information requested on this form is the same as the informationrequested during the initial patient session at the doctor's office.

The patient may desire to change their login password for the patientportal. The “Change Password” button will allow the password to bechanged. To change the password, the patient must enter the oldpassword, and then enter the new desired password with confirmation.

To enhance the patient experience, the kiosk tablet will provideopportunities for education and entertainment. This is achieved bygiving the patient access to a select set of websites specificallychosen for patient enrichment. A button will be available on the menu inthe patient portal called “Information”, which when clicked will displaya list of links that the patient is allowed to access.

There are 3 levels to the selection process for websites. First, thesystem may provide a list of websites that all patients will have theability to access. Second, the group will be able to provide a list ofwebsites that the patient may access. Third, the exam site can add moresites to which the patient should be granted access.

Typically, these sites will be educational (YouTube videos, lenssuppliers, frame manufacturers, etc.). Access may also be granted toentertainment sites such as news, weather, and sports.

The kiosk hardware is a tablet computer that is configured to allow onlyone application to be run, and that is the custom kiosk software. Whenthe kiosk is booted-up, the kiosk software will run automatically withno intervention required from anyone at the doctor's office.

The kiosk software is an application centered around a custom webbrowser, designed to give the patient access to a limited number ofwebsites. The primary website that is available is the patient portal.This website provides information to the patient about current andprevious examinations.

The portal will optionally allow patients to have access to externalwebsites for educational and/or entertainment value, while waiting foran examination. The website available to the patient will be chosen bythe group, and the exam site. To restrict the websites that areavailable to the patient, the kiosk software will occasionally request awhitelist from the portal server. This whitelist will then be used toblock any website that is not on the whitelist.

The patient portal will also have a series of links, which will allowthe patient to browse the permitted websites. The links are notavailable while the patient is initially setting up their profile on thesystem, but once the patient has setup their profile, the links will bemade available.

To configure the allowed links and whitelist, the administrator, group,and site logins will have a configuration option available for settingthese items on the website.

B. The Local Technician

The local technician in the system is always physically located at theexam site. The local technician takes care of registering the patient,collecting patient history, and walking the patient through the entireexam process. The local technician also performs the initialpre-refraction tests prior to the actual refraction by a remotetechnician and the final review by a remote doctor. Such tests mayinclude non-contact tonometry glaucoma test, color blindness test,autorefractors and aberrometers.

If the patient is wanting contact lenses, the local technician may bedirected by the remote doctor to ask the patient try on specific triallenses, collect additional slit lump images or videos with the triallenses in place, and then attach the resulting media files to thepatient's exam record so the remote doctor can verify the fit and makeadjustments as needed.

If the local technician is unable to recall their login password orusername, they can use the “Forgot Password?” or “Forgot Username?”recovery options as long as they still remember their email address. Therecovery options will email the recovery instructions to the localtechnician's email address If they are unable to recall their emailaddress, they must contact the system administrator.

The local technician directly participates in a patient's eyeexamination and all results of the tests they perform at the exam siteare reviewed by the remote doctor. The role of the local technician isprimarily to observe the activity going on at their exam site and tomaintain local technician information and occasionally patientinformation for their exam site.

1. Eye Examination Operations

The various steps of an eye exam that are performed by the localtechnician after they login are described below. The remote technicianand remote doctor take over after the local technician has performed thepre-refraction tests. Their roles in the process are covered separatelyin the remote technician and remote doctor sections.

As shown in FIG. 2, the local technician performs the following steps.

Step 1: New Patient Registration 2001. This step is not required if thepatient has ever had a previous eye exam done at an exam site in thesame group as this exam site, otherwise the local technician mustregister the patient into the system. The demographic and patientmedical and visual history information can be entered directly by thepatient using a kiosk tablet, or the local technician can enter thisinformation for them if the patient prefers during a privateconsultation.

If the patient entered this information themselves using a kiosk tablet,they can now log into their patient portal using the ID and passwordthey just supplied. If the local technician entered all the patientinformation for them using the local technician's computer, the localtechnician can now log back into the web site normally.

Step 2: Check Availability 2002. This step is where the logged in localtechnician chooses the “Check Availability” menu option to select apatient and begin the eye exam process. Other patient search options arealso available from the drop down list.

A local technician may determine that the patient wants to see the firstavailable remote technician and remote doctor rather than waiting for aspecific remote technician or remote doctor. The number of logged inremote technicians and remote doctors who can see this patient will bedisplayed after the selections have been made.

Alternatively, the local technician may searched for specific remotetechnicians or remote doctors based on skills, acceptance of thepatient's insurance, and language. (Special note: Only doctors licensedin the state where the exam site is located will be allowed to see thepatient.)

After the local technician is finished selecting the patient, and theremote technician and remote doctor choice has been selected, the localtechnician dashboard will appear.

Step 3: Patient Waiting for Local technician—Add Patient Medical History2003. At this point, the local technician dashboard will automaticallyappear and the selected patient will now appear in the “Patient Waitingfor Local Technician” list. The patient medical history should now bereviewed and attached to the current eye exam. If the patient updatedtheir medical history through the patient portal prior to their eye examappointment, this process will be as simple as verifying the currenthistory information with the patient and clicking the “Submit” button.If the patient has not recently updated their history form through thepatient portal, the local technician must consult with the patient andupdate the history info for them at this time.

After the patient medical history form has been completed, the localtechnician will click the “Submit” button and the local techniciandashboard will once again appear.

Step 4: Patient Waiting for Local Technician—Start Session 2004. Whenthe local technician is ready to begin the local exam tests for aspecific patient, they will click that patient's “Start Session” button.

At this point, the machine interface software should be running in thebackground of the local technician's computer and they will click the“Send Patient ID” button. The machine interface will accept the patientID sent by the web site and will bring itself to the front of the webbrowser and be ready to accept data from interfaced local exam machinesThe machine interface will use the patient ID to identify all local examtests performed during the current local exam test session.

Step 5: Local Exam Tests 2005. The local technician will now perform allrequired pre-refraction local exam tests for the current patient. Theinterfaced exam site machines will send the test results to the machineinterface. When all local exam tests have been completed, the localtechnician will click the “Save All Exam Tests” button and all examtests and associated media files will be sent to the web site andattached to the patient's current exam record.

An example of the machine interface screen is shown in FIG. 3.

Step 6: Submitting Exam Test Data 2006. The machine interface should nowbe minimized by clicking the - or X buttons on the top right corner ofthe main machine interface menu and the local technician's browserwindow should reappear. The exam tests the local technician just savedin the machine interface should show up in the “Completed Exam Tests”list within 60 seconds. Alternatively, the local technician can clickthe browser “Refresh” button to force the list to update itselfimmediately. The local technician can go back and repeat step 5 again ifthey need to perform additional tests for some reason. When the localtechnician has finished all local exam tests and is satisfied theresults of all tests were transferred properly to the web site, thelocal technician will click the “Submit” button at the bottom of thelocal technician observation page.

Pinhole Visual Acuity: The local technician will typically begin thepre-refraction test by performing a pinhole visual acuity test on eacheye. If the visual acuity results during this test indicate an issuewith the patient's vision that cannot be corrected with a subjectiverefraction, the local technician will typically terminate the eyeexamination with a referral to a local doctor.

Step 7: Patient Waiting on Remote Technician 2007. After successfullycompleting the prior step, the patient will be automatically moved tothe “Patient Waiting for Remote Technician” list. At this point duringthe patient's exam process, the local technician can do the following asit relates to a specific patient:

-   -   The video conference and subjective refraction “Session” with        the remote technician can be started (if a remote technician has        selected the patient).    -   The exam tests done up to this point can be viewed or optionally        printed.    -   The exam can be terminated (the local technician will be        required to provide a reason for the termination)    -   The patient can be reassigned to a different remote technician        and/or remote doctor. When the “Start Session” button appears        for a specific patient, this means a remote technician has        selected the patient and is ready to begin a video conference        and perform the subjective refraction. The local technician        should position the patient properly behind the Phoropter and        click the “Start Session” button when the button appears. This        will begin the session with the remote technician.

Step 8: Video Conference and Remote Refraction 2008. The videoconference window will now appear in the local technician's browser. Thelocal technician will selected the specific webcam they want to use fromthe drop-down list and then they will click the button to start thevideo conference. If the remote technician has their video enabled, alive image will appear on the local technician's screen. If the remotetechnician has not enabled their video, the conference will be audioonly. Either way, the remote technician, local technician, and patientwill interact with one another as though they were located in the sameroom. The web site may popup a message asking for permission to use thelocal technician's camera and microphone. The local technician mustselect “Allow” or the video conferencing with the remote technician willnot work. At this point the local technician must click the “AllowPhoropter Connection” button which will allow the remote technician toconnect to the phoropter in the exam room and then the remote subjectiverefraction will begin. The refraction will include the same proceduresand tests that are typically used during a non-remote subjectiverefraction.

(Section III.C titled “Remote Technician” has further detail about theremote technician's role in this part of the process.)

When the remote technician has finished the refraction, the videoconference will end and the patient will be automatically moved to the“Patient Waiting for Remote Doctor” list.

Step 9: Patient Waiting on Remote Doctor 2009. After successfullycompleting the prior step, the patient will be automatically moved tothe “Patient Waiting on Remote Doctor” list. At this point during thepatient's exam process, the local technician can do the following as itrelates to a specific patient:

-   -   The video conference and optional subjective refraction        “Session” with the remote doctor can be started (If a remote        doctor has selected the patient).    -   The exam tests done up to this point can be viewed or optionally        printed.    -   The exam can be terminated (the local technician will be        required to provide a reason for the termination)    -   The patient can be reassigned to a different remote doctor.

When the “Start Session” button appears for a specific patient, thismeans a remote doctor has selected the patient and is ready to begin avideo conference and begin the doctor evaluation. The local technicianshould position the patient properly behind the phoropter in case thedoctor wants to verify or refine the remote technician's subjectiverefraction. The local technician should then click the “Start Session”button when the button appears. This will begin the session with theremote doctor.

Step 10: Video Conference and Optional Remote Refraction 2010. The videoconference window will now appear in the local technician's browser. Thelocal technician will select the specific webcam they want to use fromthe drop-down list and then they will click the button to start thevideo conference. If the remote doctor has their video enabled, a liveimage will appear on the local technician's screen. If the remote doctorhas not enabled their video, the conference will be audio only. Eitherway, the remote doctor, local technician, and patient will interact withone another as though they were located in the same room.

The web site may popup a message asking for permission to use the localtechnician's camera and microphone. The local technician must select“Allow” or the video conferencing with the remote doctor will not work.

At this point the doctor's evaluation of all exam test data collected upto this point will begin. The doctor may optionally choose to verify orrefine the power of the subjective refraction done by the remotetechnician. The refraction will include the same procedures and teststhat are typically used during a non-remote subjective refraction. Theremote doctor will instruct the local technician to click the “Allowphoropter Connection” button (shown on the screen above) if the remotedoctor decides to connect to the exam room phoropter and verify orrefine the refraction.

(Section IVIED titled “Remote Doctor” has further detail about theremote doctor's role in this part of the process.)

When the remote doctor has completed the evaluation, the videoconference will end and the patient will be automatically moved to the“Patient Waiting for Rx Print” list.

Step 11: Patient Waiting for Rx Print 2011. Patients who appear in thislist have already completed their eye examination and new eyeglass andoptional contact lens prescriptions have been authorized by the remotedoctor. If the patient wants a copy of their prescription emailed, thelocal technician should click the “Email Prescription” button first andthen click the “Print Prescription” button last. The prescription(s)will contain complete information you would typically find on anon-remote eye examination prescription along with the examiningdoctor's signature.

Step 12: Eye Exam Completed 2012. When the local technician hascompleted the previous step by printing a copy of the patient'sprescription(s), the patient is automatically removed from all waitinglists and their eye exam is finished.

If the local technician, remote technician, or remote doctor terminatesa patient's eye exam at any point before the prescription is issued, thepatient will be moved directly into the “Patient Terminated Exams” listwhich is the very last list shown on the local technician dashboard.

If the local technician views or prints the “prescription” for aterminated exam, it will contain the reason the exam was terminated andthe person's name who terminated the exam. This list is cleared eachday, so it will only include patients who were terminated during thecurrent day.

2. Maintenance Operations

The various maintenance operations that can be performed by the localtechnician after they login are described below.

Local technician dashboard. The local technician dashboard displays alist of patients currently waiting for the next stage of their eye exam.This allows the local technician to see at a glance the status of everypatient who is waiting. The local technician login does not have aninactive timeout, so they will not be logged out of the web site forinactivity.

This local technician dashboard allows the local technician to performthe following tasks:

-   -   The local technician can view a list of all patients at the exam        site who are currently waiting to be seen by the local        technician who is logged into the system. The patients in this        list will appear in order of how long they have been waiting for        a local technician with those who have been waiting the longest        appearing at the top of the list.    -   The local technician can view a list of all patients at the exam        site who are currently waiting to be seen by a remote technician        to have their subjective refraction performed. The patients in        this list will appear in order of how long they have been        waiting for a remote technician with those waiting the longest        appearing at the top of the list. This list will also indicate        if the patient is still waiting for a remote technician or if        they are already in an active session with a remote technician.    -   The local technician can view a list of all patients at the exam        site who are currently waiting to have the results of all the        exam and refraction tests reviewed by a remote doctor. The        patients in this list will appear in order of how long they have        been waiting for a remote doctor with those waiting the longest        appearing at the top of the list. This list will also indicate        if the patient is still waiting for a remote doctor or if they        are already in an active session with a remote doctor.

The local technician dashboard provides the local technician with a goodoverview of what is going on in their specific exam site location as itinvolves them. The local technician does not have an inactive timeout,so a local technician can stay logged in 24 hours a day without anyworry of being logged out.

Check Availability. The Check Availability menu option allows the localtechnician to start the exam process for a patient who is alreadyregistered in the system. Much more detail about the use of this menuoption is included in step 2 of the “Eye Examination” section of thisdocument.

Manage Patients. The local technician can use this menu option toperform the following tasks:

-   -   Add a new patient to this exam site    -   Edit the detail for an existing patient    -   Manage documents for an existing patient (scans of medical        records, insurance cards, driver's license, etc.)    -   View the details for an existing patient    -   View and optionally print the current and past exam results and        prescriptions for a patient    -   Email a copy of a prescription to a patient

The patient is required to agree to the terms and the patient'ssignature is also required.

View Report. This menu option allows the local technician to do thefollowing tasks:

-   -   Select the desired report type from the list of reports        available to local technicians    -   Select the date range for the report    -   Submit the choices to create the report    -   View the resulting report    -   Print the resulting report    -   Export the resulting report    -   Search within the report

Reports available to the local technician will vary as additionalreports are added by the system administrator.

Update Profile. The update profile menu option allows the localtechnician to view and update their profile details.

Information. This menu option will display a list of subjects availablethrough internet links made available and assigned by systemadministrators. The subjects will typically be for training purposes,but the subject of the internet links made available through this menuoption will be appropriate for local technicians and will be controlledremotely by system administrators and can be changed remotely at anytime

Change Password. This menu option simply allows the local technician tochange their login password. The “Change Password” option requires thelocal technician to enter their old password, enter the new password,and confirm the new password. Certain requirements must be met on thecomplexity of the new password or the change will not be allowed.

After the local technician has successfully changed their password, theymust log back in using the new password before they can continue usingthe system.

C. Remote Technician

The remote technicians in the system are responsible for performing thesubjective refraction part of the eye exam prior to the patient beingtransferred to the remote doctor. The phoropter equipment and eye chartused for the subjective eye exam is controlled remotely by the remotetechnician using special controller software running at the remotetechnician's location.

A video conference session is established between the remote technician,the patient, and the local technician during the subjective refraction.This allows the remote technician, local technician, and patient tointeract with each other during the subjective refraction in the sameway they would interact if the refraction was being performed locally.This interaction combined with the special digital refraction equipmentallows the remote technician to perform an extremely accurate subjectiverefraction and accurately check and record the patient's visual acuity.

The remote technician is allowed to review the lensometry,auto-refractor, and any subjective refraction test results that may havebeen previously performed during each exam session. The remotetechnician is not allowed to see the results of any other exam testsbecause the remaining tests must be evaluated by a remote doctor.

After the remote technician has completed all subjective refractiontests, the subjective refraction test results are reviewed by a remotedoctor. The remote doctor can verify and even adjust the subjectiverefraction test results if they so desire by using the video conferencesystem and controlling the phoropter exactly the same way as the remotetechnician.

If the remote technician is unable to recall their login password orusername, they can use the “Forgot Password?” or “Forgot Username?”recovery options. Both recovery options will email the recoveryinstructions to the remote technician's email address. If the remotetechnician is unable to recall the email address that was used whentheir account was created, they will not be able to use these recoveryoptions. In that case, they must contact the system administrator.

The remote technician directly participates in the patient's eyeexamination, but they also have a few maintenance operations they canperform as needed.

1. Eye Examination Operations

As shown in FIG. 4, the various subjective refraction related eyeexamination operations that are performed by the remote technician afterthey login are described below.

Step 1: Remote Technician Dashboard 4001. The remote techniciandashboard provides the remote technician the ability to get a goodoverview of everything in the system that will involve the specificremote technician who is logged in. The remote technician login has a 30minute timeout, so they will be logged out of the system automaticallyif they have not performed any operations within the last 30 minutes.

This remote technician dashboard allows the remote technician to performthe following tasks:

-   -   The remote technician can view a list of all patients currently        waiting to have their subjective refraction performed. This list        will contain patients waiting for any remote technician and        patients waiting for this specific technician. Patients who are        waiting for a different remote technician will not appear in        this list. The patients in this list will appear in order of how        long they have been waiting with those waiting the longest        appearing at the top of the list.    -   The remote technician can view a waiting patient's previous        lensometry, auto-refractor, or refraction test results.    -   The remote technician can terminate an eye examination for any        reason. If the remote technician terminates an eye examination,        they are required to enter the reason they terminated the exam.    -   The remote technician can start the subjective refraction        session. When the session begins, the remote technician will        begin a video conference with the patient and begin the        subjective refraction by remotely controlling the phoropter.

Step 2: Begin Video and/or Audio Conference with Patient 4002. When theremote technician clicks the “Session” button, the remote technicianshould then select the webcam they want to use for the video conferencewith the local technician and patient from the drop down list. After thecorrect webcam is selected, they should then click the icon to send asignal to the local technician that the remote technician is ready tobegin the refraction. The video conferencing system allows the remotetechnician to communicate and interact with the patient and localtechnician as though they were in the same room.

The web site may popup a message asking for permission to use the remotetechnician's camera and microphone. The remote technician must select“Allow” or the video conferencing with the patient and local technicianwill not work.

Step 3: Subjective Refraction Exam Session 4003. After the videoconference session has been established, the remote technician will thenclick a button on the web page to connect to the phoropter in the examlane where the patient is located. At the same time, the localtechnician will use a button on their web page to allow the connection.Security implemented in this system makes it impossible for a remotetechnician to connect to the wrong phoropter. Once thecontroller/phoropter/eyechart connection has been established, theremote technician will have control of the phoropter and the eyechartand can begin the refraction. The digital equipment being used in thissystem allows the remote technician to perform a complete subjectiverefraction mid related tests that will be at least as accurate asperforming these tests locally. The remote technician will observe allprecautions and “best practice” techniques as would be used for atypical non-remote subjective refraction.

Normal Visual Acuity: The remote technician will check the patient'svisual acuity for each eye and then for both eyes together under thefollowing conditions:

-   -   With no correction for the right and left eye    -   With no correction for both eyes together    -   With their previous prescription for the right and left eye    -   With their previous prescription for both eyes together

Subjective Distance Vision Refraction: The remote technician willremotely control the phoropter and eye chart to perform a distancevision subjective refraction on each eye. The subjective refractiontests performed for distance vision will be the same as the testsnormally performed during a non-remote subjective eye examination. Thesteps will typically include the following and in the following order:

-   -   Refine the right eye sphere power    -   Refine the right eye cylinder axis    -   Refine the right eye cylinder power    -   Refine the right sphere power one last time    -   Refine the left eye sphere power    -   Refine the left eye cylinder axis    -   Refine the left eye cylinder power    -   Refine the left sphere power one last time    -   Refine the right eye sphere using the Red/Green duochrome test    -   Refine the left eye sphere using the Red/Green duochrome test    -   Perform the binocular balance tests with both eyes together

Subjective Near Vision Refraction: The remote technician will remotelycontrol the phoropter and eye chart to perform a typical near visionrefraction if the patient is beyond a certain age or if the patientindicates they are having difficulty seeing at close distances orreading. The subjective refraction tests performed for near vision willbe the same as the tests typically performed during a non-remotesubjective eye examination.

Final Visual Acuity: The remote technician will now use the eye chart toperform the final visual acuity check for distance and near with the newprescription and save all test results.

-   -   New distance vision visual acuity for the right eye    -   New distance vision visual acuity for the left eye    -   New distance vision visual acuity with both eyes together    -   New near vision visual acuity for the right eye    -   Now near vision visual acuity for the left eye    -   New near vision visual acuity with both eyes together

The phoropter and eye chart controller is not necessarily the propertyof the system so the appearance and functionality of the controller willvary from one equipment manufacturer to another. An example of thecontroller menu that is used by the remote technician to remotelycontrol a Reichert VRx phoropter and eye chart during the subjectiverefraction is shown in FIG. 5.

Step 4: Transfer the Subjective Refraction and Visual Acuity TestResults to the Web Site 4004: When the remote technician has completedall subjective refraction tests, the results of all tests are sent fromthe phoropter to the machine interface at the exam site, and then on tothe web site. The remote technician will then click the “Get RefractionData” button and the newest refraction done during the current examsession will be loaded into the form. The remote technician can thenchoose the type of lens the patient requests or that is indicated by thepatient's required lens power. The remote technician may also choose toadd comments for the remote doctor who will be doing the finalevaluation.

Step 5: Final Review and Transfer to the Remote Doctor 4005: When theremote technician is satisfied all important information has been added,they will click the submit button. The web site will verify everythingis valid and will then take the remote technician back to the remotetechnician dashboard and remove the patient from the patient waitinglist. At this point, the patient will be moved into the remote doctor'swaiting list.

2 Maintenance Operations

The various maintenance operations that can be performed by the remotetechnician after they login are described below.

Remote Technician Dashboard. The remote technician dashboard providesthe remote technician the ability to see a list of patients who arewaiting for retractions. Details about the remote technician dashboardare included in the previous “Eye Exam Operations” section of thisdocument.

View Report. This menu option allows the remote technician to do thefollowing tasks:

-   -   Select the desired report type from the list of reports        available to remote technicians    -   Select the date range for the report    -   Submit the choices to create the report    -   View the resulting report    -   Print the resulting report    -   Export the resulting report    -   Search within the report

Reports available to the remote technicians will vary as additionalreports are added by the system administrator.

Update Profile. The update profile menu option allows the remotetechnician to view and update their profile details

Information. This menu option will display a list of subjects availablethrough internet links made available and assigned by systemadministrators. The subjects will typically be for training purposes andappropriate for remote technicians. The subject of the internet linksmade available through this menu option is controlled remotely by systemadministrators and can be changed remotely at any time.

Change Password. This menu option allows the remote technician to changetheir login password. The “Change Password” option requires the remotetechnician to enter their old password, enter the new password, andconfirm the new password. Certain requirements must be met on thecomplexity of the new password or the change will not be allowed. Afterthe remote technician has successfully changed their password, they mustlog back in using the new password before they can continue using thesystem.

D. Remote Doctor

The remote doctors in the system are responsible for evaluating theresults of all tests performed during the eye examination process andthey may optionally verify or refine the subjective refraction performedby the remote technician. The phoropter equipment and eye chart used forthe subjective eye exam can be controlled remotely by the remote doctorusing special controller software running at the remote doctor'slocation.

A video conference session is established between the remote doctor, thepatient, and the local technician during the doctor's evaluationsession. This allows the remote doctor, patient, and local technician tointeract with each other in the same way they would interact if thedoctor's evaluation was being performed locally. This interactioncombined with the use of the most modern examination equipment allowsthe remote doctor to perform an extremely thorough evaluation that is atleast as accurate as a non-remote doctor evaluation.

The remote doctor is required to review the results of all exam teststhat have been previously performed during each exam session includingany media files that may be attached to any exam test. The doctor isalso allowed to review all patient history information and anyinformation collected during any previous eye exam that is on file. Theremote doctor is also allowed to verify or refine any subjectiverefraction previously performed during this exam session.

After the remote doctor has reviewed everything, they may issue aprescription for eyeglasses, optionally issue a prescription for contactlenses, or they may choose to terminate the eye exam. The doctor willnot issue a contact lens prescription unless the patient has requestedcontact lenses and all contact lens related tests and fitting operationshave been successfully performed.

If the remote doctor is unable to recall their login password orusername, they can use the “Forgot Password?” or “Forgot Username?”recovery options. Both recovery options will email the recoveryinstructions to the remote doctor's email address. If the remote doctoris unable to recall the email address that was used when their accountwas created, they will not be able to use these recovery options. Inthat case, they must contact the system administrator.

The remote doctor directly participates in the final steps of thepatient's eye examination and makes the final decisions, but they alsohave a few maintenance operations they can perform as needed.

1 Eye Examination Operations

As shown in FIG. 6, the various evaluation and subjective refractionrelated operations that can be performed by the remote doctor after theylogin are described below.

Step 1: Remote Doctor Dashboard 6001. The remote doctor dashboardprovides a good overview of everything in the system that will involvethe specific remote doctor who is logged in. The remote doctor login hasa 30 minute timeout, so they will be logged out of the systemautomatically if they have not performed any operations within the last30 minutes.

This remote doctor dashboard allows the remote doctor to perform thefollowing tasks:

-   -   The remote doctor can view a list of all patients currently        waiting to have their eye exam tests evaluated and their        eyeglass and optionally contact lens prescriptions issued. This        list will contain patients waiting for any remote doctor and        patients waiting for the specific doctor who is logged in.        Patients who are waiting for a different remote doctor will not        appear in this list. The patients in this list will appear in        order of how long they have been waiting with those waiting the        longest appearing at the top of the list.    -   The remote doctor can see the group and exam site name and        address where each patient is physically located.    -   The remote doctor can view the results of all tests performed        for any waiting patient.    -   The remote doctor can terminate an eye examination for any        reason. If the remote doctor terminates an eye examination, they        are required to enter the reason they terminated the exam.    -   The remote doctor can start the eye exam evaluation session.        When the session begins, the remote doctor will typically begin        a video conference with the patient, begin evaluating the test        results, and optionally control the phoropter remotely if they        want to verify or refine the subjective refraction results.

Step 2: Begin Video and/or Audio Conference with Patient 6002. When theremote doctor clicks the “Add Prescription” button as shown on thedoctor's dashboard above, the webcam and prescription web pages willdisplay. The remote doctor should then select the webcam they want touse for the video conference with the local technician and patient fromthe drop down list. After the correct webcam is selected, they shouldthen click the icon to send a signal to the local technician that theremote doctor is ready to see the patient and begin the evaluationsession.

The web site may popup a message asking for permission to use the remotedoctor's camera and microphone. The remote doctor must select “Allow” orthe video conferencing with the patient and local technician will notwork. The video conferencing system allows the remote doctor tocommunicate and interact with the patient and local technician as thoughthey were in the same room.

Step 3: Optional Subjective Refraction Verification or Refinement 6003.After the video conference session has been established, the remotedoctor can optionally verify or refine the refraction done by the remotetechnician. A button on the web page allows them to connect to thephoropter in the exam lane where the patient is located. At the sametime, the remote doctor will use a button on their web page to allow thephoropter connection. Security implemented in this system makes itimpossible for a remote doctor to connect to the wrong phoropter. Oncethe controller/phoropter/eyechart connection has been established, theremote doctor will have control of the phoropter and the eyechart andcan begin the refraction verification or refinement. The digitalequipment being used in this system allows the remote doctor to performa subjective refraction and related tests that will be at least asaccurate as performing these tests locally. The remote doctor willobserve all precautions and “best practice” techniques as would be usedfor typical a non-remote subjective refraction if they do choose toverify or refine the refraction during their evaluation.

The phoropter and eye chart controller is not the property of the systemso the appearance and functionality of the controller will vary from oneequipment manufacturer to another. An example of the controller menuthat may be used by the remote doctor to remotely control a Reichert VRxphoropter and eye chart is shown in FIG. 5. Another model of a phoroptermay also be used.

Step 4: Doctor Evaluation 6004. The video conference will continue whilethe remote doctor is reviewing all exam test results for the currentpatient. The doctor may choose to carry on a conversation with thepatient while the test results are being examined. The web site will NOTallow the doctor to issue a prescription until they have reviewed theresults of every exam test, all attached media files, and the patient'svisual and medical history information. This system behavior assuresthat the remote doctor will review everything available, which makes thesystem significantly more thorough than a typical non-remote eyeexamination.

When the remote doctor has reviewed an exam test for the current examsession along with all media files attached to the exam test, the tabfor that exam test will turn green. Exam test results that have not beenfully reviewed will remain light blue.

In addition to the exam tests, the remote doctor is also required toreview the patient's visual and medical history information before theyare allowed to issue a prescription.

The remote doctor may choose to review information from prior eye exams,but they are not required to do so.

The remote doctor will click the “Copy Refraction to This Form” buttonwhen they are satisfied the most recent refraction done during today'seye exam is accurate and correct. This will automatically load the mostrecent refraction data into the remote doctor's prescription form.

If the patient requested contact lenses and adequate testing has beendone to proceed with a contact lens exam, the doctor will place a checkmark in the “Add Contact Lens Prescription” checkbox. The remote doctormay instruct the local technician through the video conferencing systemto have the patient insert specific trial contact lenses and provideadditional slit lamp images and/or video so the remote doctor canevaluate the fit. The doctor will repeat this process until the contactlens is correct.

Start Video Conferencing system. The remote doctor will typically beginthe evaluation with the patient by starting a video conference session.This will allow the doctor to interact with the patient in the same waythey would do in a non-remote eye exam.

Review Exam Test Results: The remote doctor will review all exam testsresults and this will typically involve the following:

-   -   Mandatory: Review all exam tests performed by the local and        remote technicians. This will include all tests that are        normally performed during a typical non-remote eye examination.    -   Mandatory: Review all media files that may be attached to any        exam test.    -   Mandatory: Review the patient's medical history.    -   Optional: Verify or refine the subjective refraction by the        remote doctor's use of the phoropter remotely and applying        professional judgement.    -   Optional: View the exam test results of any previous eye exam        performed through this system.    -   Optional: View the patient history attached to any previous eye        exam performed through this system.    -   Mandatory: Issue an eyeglass prescription or the doctor may        choose to terminate the eye exam and provide a referral if        necessary in their professional opinion. If the doctor        terminates the exam, they MUST provide a reason and optionally        provide a referral.    -   Optional: They may issue a contact lens prescription if the        patient asks for contacts and all tests and fitting requirements        for contact lenses have been successfully performed.

Step 5: Final Review and Submit Prescription(s) 6005. The remote doctorcan now optionally attach comments to the final prescriptions beforesubmitting them to the system. When the remote doctor is satisfied allimportant information has been added to the prescription(s), they willclick the submit button. The web site will verify everything is validand will then take the remote doctor back to the remote doctor dashboardand remove the patient from the patient waiting list.

The remote doctor is now ready to see the next patient that appears intheir waiting list.

2. Maintenance Operations

The various maintenance operations that can be performed by the remotedoctor after they login are described below.

Remote Doctor Dashboard. The remote doctor dashboard provides the remotedoctor the ability to see a list of patients who are waiting for adoctor to see them and evaluate the test results and issue theirprescription(s) Details about the remote doctor dashboard are includedin the previous “Eye Examination Operations” section of this document.

View Report. This menu option allows the remote doctor to do thefollowing tasks:

-   -   Select the desired report type from the list of reports        available to remote doctors    -   Select the date range for the report    -   Submit the choices to create the report    -   View the resulting report    -   Print the resulting report    -   Export the resulting report    -   Search within the report

Reports available to the remote doctors will vary as additional reportsare added by the system administrator.

Update Profile. The update profile menu option allows the remote doctorto view and update their profile details.

Information. This menu option will display a list of subjects availablethrough internet links made available and assigned by systemadministrators. The subjects will typically be for training purposes andappropriate for remote doctors. The subject of the internet links madeavailable through this menu option is controlled remotely by systemadministrators and can be changed remotely at any time.

Change Password. This menu option allows the remote doctor to changetheir login password. The “Change Password” option requires the remotedoctor to enter their old password, enter the new password, and confirmthe new password. Certain requirements must be met on the complexity ofthe new password or the change will not be allowed. After the remotedoctor has successfully changed their password, they must log back inusing the new password before they can continue using the system.

V. Maintenance Operations

The following provides a comprehensive description of role of eachparticipant in the maintenance of the apparatus, method, and system forremote comprehensive eye examinations: the system administrator, thegroup administrator and the exam site administrator.

A. System Administrator

1. Overview

The system administrator users oversee the entire system. They cancreate new groups, exam sites, remote technicians, remote doctors, andsupported insurances as needed and perform other system maintenanceactivities. The system administrators will typically be high levelmanagers.

If a system administrator is unable to recall their login password orusername, they can use the “Forgot Password?” or “Forgot Username?”recovery options. Both recovery options will email the recoveryinstructions to the system administrator's email address. The systemadministrator does not directly participate in a patient's eyeexamination. The role of the system administrator is primarily toobserve the activity going on within the system and to maintain andmanage the groups, exam sites, remote technicians and remote doctors.

2. Operations

The various system maintenance operations that can be performed by thesystem administrator after they login are described below.

Manage Administrators. The system administrator uses this menu option tomanage the system administrators in the system. This menu option allowsthe system administrator to perform the following tasks:

-   -   Add system administrators into the system    -   Add, edit, delete, and manage documents for system        administrators that are currently in the system (only available        to administrators with “Super” status)    -   View detail about system administrators currently in the system    -   Maintain documents for any group or any exam site within any        group

Manage Groups. The system administrator uses this menu option to managethe groups in the system. This menu option allows the systemadministrator to perform the following tasks:

-   -   Add new groups into the system    -   Delete groups that are currently in the system    -   Add, delete, view, or edit exam sites for any group currently in        the system    -   View or edit the exam pricing currently assigned to any group    -   View or Edit the exam pricing currently assigned to any exam        site in any group    -   Maintain documents for any group or any exam site within any        group    -   View the detail for any group currently in the system

Manage Local Technicians. The system administrator can manage the localtechnicians who are allowed to perform pre-refraction tests at each ofthe group's exam sites. This menu option allows the system administratorto perform the following tasks:

-   -   Add a new local technician to any existing group    -   Edit the details for an existing local technician in any group.    -   Delete an existing local technician that is in any group    -   View the detail for an existing local technician in any group    -   Specify the exam site where each local technician is allowed to        perform their work    -   Manage and view Documents for an existing local technician in        any group

Manage Remote Technicians. The system administrator can this menu optionto perform the following tasks:

-   -   Add a new remote technician to the system    -   Edit the details for an existing remote technician    -   Delete an existing remote technician    -   View the detail for an existing remote technician    -   Specify the exam site where each remote technician is allowed to        perform their work    -   Manage and view Documents for an existing remote technician

Manage Patients. This menu option allows the system administrator to dothe following tasks

-   -   Search and View a list of patients currently in the system    -   Delete a patient from the system

The primary use of this menu option is to remove old patient records orexperimental records that no longer need to be in the system.

View Report. This menu option allows the system administrator to do thefollowing tasks:

-   -   Select the desired report type from the list of reports        available to the main system administrators    -   Select the date range for the report    -   Submit the choices to create the report    -   View the resulting report    -   Print the resulting report    -   Export the resulting report    -   Search within the report

Reports available to the system administrator will vary as additionalreports are added by the system administrator.

Manage Doctors. The system administrator can use this menu option toperform the following tasks:

-   -   Add a new doctor to the system    -   Edit the details for an existing doctor    -   Delete an existing doctor    -   View the detail for an existing doctor    -   Specify the exam site where each doctor is allowed to perform        their work    -   Manage and view documents for an existing doctor

Manage Insurances. The system administrator uses this menu option toperform the following tasks:

-   -   Add a new insurance program to the system    -   Edit the details for an existing insurance program    -   Delete an existing insurance program    -   View the detail for an existing insurance program    -   Manage and view documents for an existing insurance program

Manage Report. This menu option allows the system administrator tocreate new reports and edit existing reports. The system administratorcan specify what login type is able to view each report.

Manage Pricing. This menu option is a utility that allows the systemadministrator to change the prices on large numbers of groups and examsites at once.

Patient Waiting List. This menu option allows the system administratorto see a list of patients currently waiting to be seen at all examsites. The primary purpose of this option is to allow a systemadministrator to observe the patient waiting times and possibly takeaction if an excessive waiting time is observed on any patient.

Manage Patient Portal. This menu option allows the system administratorto enter, edit, or delete the internet links and link descriptions thatwill be available to patients who visit any exam site in the system whenthey sign into their patient portal. These links are used for patienteducation and for entertainment purposes, such as news, weather, orsports information. This feature allows the system administrator toassign custom links for entertainment or education in addition toproviding information about the eye exam process itself and how itworks. The purpose of this feature is to significantly enhance thepatient experience by incorporating patient portal tablets into the examprocess.

If a patient signs into the patient portal using the patient portalkiosk, the patient will be presented with a menu option that will allowthem to visit only the web sites specified by the main systemadministrator, the group administrator, and the exam site administrator.The same educational and entertainment links will be available if theysign into the patient portal from their home or work computer, but theirbrowser will not be restricted as to where it can go.

Update Profile. This menu option allows the logged in systemadministrator to update their own profile information.

Change Password. This menu option allows the system administrator tochange their login password. The “Change Password” option requires thesystem administrator to enter their old password, enter the newpassword, and confirm the new password. Certain requirements must be meton the complexity of the new password or the change will not be allowed.After the system administrator has successfully changed their password,they must log back in using the new password before they can continueusing the system.

B. Group Administrator

1. Overview

The group administrator users in the system oversee the exam siteswithin their group. They can create new exam sites/stores within theirgroup as needed and perform other maintenance activities. A chain storeoperation for example would have many exam sites within their group,whereas an independent operation may only have one exam site in theirgroup.

If the group administrator is unable to recall their login password orusername, they can use the “Forgot Password?” or “Forgot Username?”recovery options. Both recovery options will email the recoveryinstructions to the group administrator's email address. If the groupadministrator is unable to recall the email address that was used whentheir account was created, they will not be able to use these recoveryoptions. In that case, they must contact the system administrator.

The group administrator does not directly participate in a patient's eyeexamination. The role of the group administrator is primarily to observethe activity going on within their group and to maintain the exam sitesand local technicians who are part of their group.

2. Operations

The various system maintenance operations that can be performed by thegroup administrator after they login is described below.

Group Dashboard. The group administrator can view the group dashboard.This menu option allows the group administrator to perform the followingtasks:

-   -   View a list of all local technicians currently registered to        perform pre-refraction exam tests for exam sites in their group    -   View a list of all remote technicians who are able to perform        refractions for the exam sites in their group    -   View a list of remote doctors who are able to evaluate patient        exam tests, refraction results, and sign prescriptions for the        various exam sites within that group    -   View a list of all patients who are currently engaged in an eye        exam at an exam site within their group

The group dashboard provides the group administrator the ability to geta good overview of what is going on within their entire group. The groupadministrator login does not have an inactive timeout, so a monitor candisplay the group dashboard detail at the group's corporate office 24hours a day without any worry of being logged out.

Manage Local Technicians. The group administrator can manage the localtechnicians who are allowed to perform pre-refraction tests at each ofthe group's exam sites. This menu option allows the group administratorto perform the following tasks:

-   -   Add a new local technician to the group    -   Edit the details for an existing local technician in the group.    -   Delete an existing local technician that is in the group    -   View the detail for an existing local technician in the group    -   Specify the exam site where each local technician is allowed to        perform their work    -   Manage and view Documents for an existing local technician in        the group

Group Profile. The group profile menu option allows the groupadministrator to view the details about their group that has been storedin the system by the main system administrator if any of thisinformation needs to be updated, the group administrator must contactthe system administrator.

Manage Exam Sites. The group administrator can use this menu option toperform the following tasks:

-   -   Add a new exam site to the group    -   Edit the detail for any exam site in the group    -   Delete an exam site from the group    -   View the exam pricing for any exam site in the group    -   Maintain documents for any exam site in the group

View Report. This menu option allows the group administrator to do thefollowing tasks:

-   -   Select the desired report type from the list of reports        available to groups    -   Select the date range for the report    -   Submit the choices to create the report    -   View the resulting report    -   Print the resulting report    -   Export the resulting report    -   Search within the report

Reports available to the group administrator will vary as additionalreports are added by the system administrator.

View Pricing. This menu option allows the group administrator to viewthe exam pricing that is currently assigned by the system to this group.The prices displayed here for the various exam types will be used forany exam site in this group that does not have custom exam pricesassigned by the system.

Manage Patient Portal. This menu option allows the group administratorto enter, edit, or delete the internet links and link descriptions thatwill be available to patients at one of their exam sites when they signinto their patient portal. These links are used for patient educationand for entertainment purposes, such as news, weather, or sportsinformation.

This feature allows the group administrator to assign custom links foreducation or entertainment that are more focused on the needs of thepatients when they visit an exam site associated with their specificgroup. The purpose of this feature is to significantly enhance thepatient experience by incorporating patient portal tablets into the examprocess.

If a patient signs into the patient portal using the patient portalkiosk, the patient will be presented with a menu option that will allowthem to visit only the web sites specified by the main systemadministrator, the group administrator, and the exam site administrator.The same educational and entertainment links will be available if theysign into the patient portal from their home or work computer, but theirbrowser will not be restricted as to where it can go.

Information. This menu option will display a list of subjects availablethrough internet links made available and assigned by systemadministrators. The subjects will typically be for training purposes andappropriate for group administrators. The subject of the internet linksmade available through this menu option is controlled remotely by systemadministrators and can be changed remotely at any time.

Change Password. This menu option allows the group administrator tochange their login password. The “Change Password” option requires thegroup administrator to enter their old password, enter the new password,and confirm the new password. Certain requirements must be met on thecomplexity of the new password or the change will not be allowed. Afterthe group administrator has successfully changed their password, theymust log back in using the new password before they can continue usingthe system.

C. Exam Site Administrator

1. Overview

The exam site administrator in the system is the administrator for theindividual exam sites. They can create new local technicians for theirlocation as needed and perform other maintenance activities for theirexam site. If the exam site administrator is unable to recall theirlogin password or username, they can use the “Forgot Password?” or“Forgot Username?” recovery options as long as they still remember theexam site administrator's email address. The recovery options will emailthe recovery instructions to the exam site administrator's emailaddress. If they are also unable to recall the email address, they mustcontact the system administrator.

The exam site administrator does not directly participate in a patient'seye examination. The role of the exam site administrator is primarily toobserve the activity going on at their exam site and to maintain localtechnician information and occasionally patient information for theirexam site.

2. Operations

The various system maintenance operations that can be performed by theexam site administrator after they login is described below.

Exam Site Dashboard. The exam site administrator can view the exam sitedashboard. This menu option allows the exam site administrator toperform the following tasks.

-   -   View a list of all patients at this exam site who are currently        waiting on a local technician to start their pre-refraction exam        tests    -   View a list of all patients at this exam site who are currently        waiting on a remote technician to begin their refraction    -   View a list of all patients at this exam site who are currently        waiting on a remote doctor to review their exam tests and        refraction    -   View a list of all patients at this exam site who have had their        entire eye exam completed and are simply waiting to have their        prescription printed and optionally emailed

The exam site dashboard provides the exam site administrator with theability to get a good overview of what is going on in their specificexam site location. The exam site administrator login does not have aninactive timeout, so a monitor can display the exam site dashboarddetail in the back office at the exam site location 24 hours a daywithout any worry of being logged out.

Update Profile. The update profile menu option allows the exam siteadministrator to view the details about their exam site that has beenstored in the system by the main system administrator. If any of thisinformation needs to be updated, the exam site administrator mustcontact the system administrator.

Manage Patients. The exam site administrator can use this menu option toperform the following tasks:

-   -   Add a new patient to this exam site    -   Edit the detail for an existing patient    -   Manage documents for an existing patient (scans of medical        records, insurance cards, driver's license, etc.)    -   View the details for an existing patient    -   View and optionally print the current and past exam results and        prescriptions for a patient    -   Email a copy of a prescription to a patient

Manage Local Technicians. The exam site administrator can also managethe local technicians who are allowed to perform pre-refraction tests atthis specific exam site. This menu option allows the exam siteadministrator to perform the following tasks:

-   -   Add new local technicians for this exam site    -   Edit detail for an existing local technician for this exam site    -   Delete a local technician from this exam site    -   Manage and view documents for an existing local technician        (scanned certifications, licenses, etc.)    -   View the details for an existing local technician at this exam        site

View Report. This menu option allows the exam site administrator to dothe following tasks:

-   -   Select the desired report type from the list of reports        available to exam site administrators    -   Select the date range for the report    -   Submit the choices to create the report    -   View the resulting report    -   Print the resulting report    -   Export the resulting report    -   Search within the report

Reports available to the exam site administrator will vary as additionalreports are added by the system administrator.

View Pricing. This menu option allows the exam site administrator toview the exam pricing that is currently assigned by the system to thisexam site.

Manage Patient Portal. This menu option allows the exam siteadministrator to enter, edit, or delete the internet links and linkdescriptions that will be available to their patients when they signinto their patient portal. These links are used for patient educationand for entertainment purposes, such as news, weather, or sportsinformation.

This feature allows the exam site administrator to assign custom linksfor education or entertainment that are focused on the local needs oftheir specific patients. The purpose of this feature is to significantlyenhance the patient experience by incorporating patient portal tabletsinto the exam process.

If a patient signs into the patient portal using the patient portalkiosk, the patient will be presented with a menu option that will allowthem to visit only the web sites specified by the main systemadministrator, the group administrator, and the exam site administrator.The same educational and entertainment links will be available if theysign into the patient portal from their home or work computer, but theirbrowser will not be restricted as to where it can go.

Information. This menu option will display a list of subjects availablethrough internet links made available and assigned by systemadministrators. The subjects will typically be for training purposes andappropriate for exam site administrators. The subject of the internetlinks made available through this menu option is controlled remotely bysystem administrators and can be changed remotely at any time.

Change Password. This menu option simply allows the exam siteadministrator to change their login password. The “Change Password”option requires the exam site administrator to enter their old password,enter the new password, and confirm the new password. Certainrequirements must be met on the complexity of the new password or thechange will not be allowed. After the exam site administrator hassuccessfully changed their password, they must log back in using the newpassword before they can continue using the system.

VI. Conclusion

In the foregoing specification, specific embodiments have beendescribed. However, one of ordinary skill in the art appreciates thatvarious modifications and changes can be made without departing from thescope of the invention as set forth in the claims below. Accordingly,the specification and figures are to be regarded in an illustrativerather than a restrictive sense, and all such modifications are intendedto be included within the scope of present teachings.

The benefits, advantages, solutions to problems, and any element(s) thatmay cause any benefit, advantage, or solution to occur or become morepronounced are not to be construed as a critical, required, or essentialfeatures or elements of any or all the claims. The invention is definedsolely by the appended claims including any amendments made during thependency of this application and all equivalents of those claims asissued.

Moreover in this document, relational terms such as first and second,top and bottom, and the like may be used solely to distinguish oneentity or action from another entity or action without necessarilyrequiring or implying any actual such relationship or order between suchentities or actions. The terms “comprises,” “comprising,” “has”,“having,” “includes”, “including,” “contains”, “containing” or any othervariation thereof, are intended to cover a non-exclusive inclusion, suchthat a process, method, article, or apparatus that comprises, has,includes, contains a list of elements does not include only thoseelements but may include other elements not expressly listed or inherentto such process, method, article, or apparatus. An element proceeded by“comprises . . . a”, “has . . . a”, “includes . . . a”, “contains . . .a” does not, without more constraints, preclude the existence ofadditional identical elements in the process, method, article, orapparatus that comprises, has, includes, contains the element. The terms“a” and “an” are defined as one or more unless explicitly statedotherwise herein. The terms “substantially”, “essentially”,“approximately”, “about” or any other version thereof, are defined asbeing close to as understood by one of ordinary skill in the art. Theterm “coupled” as used herein is defined as connected, although notnecessarily directly and not necessarily mechanically. A device orstructure that is “configured” in a certain way is configured in atleast that way, but may also be configured in ways that are not listed.

The Abstract of the Disclosure is provided to allow the reader toquickly ascertain the nature of the technical disclosure. It issubmitted with the understanding that it will not be used to interpretor limit the scope or meaning of the claims. In addition, in theforegoing Detailed Description, it can be seen that various features aregrouped together in various embodiments for the purpose of streamliningthe disclosure. This method of disclosure is not to be interpreted asreflecting an intention that the claimed embodiments require morefeatures than are expressly recited in each claim. Rather, as thefollowing claims reflect, inventive subject matter lies in less than allfeatures of a single disclosed embodiment. Thus the following claims arehereby incorporated into the Detailed Description, with each claimstanding on its own as a separately claimed subject matter.

What is claimed is:
 1. A system for facilitating comprehensive eyeexaminations, comprising: a diagnostic center including: ophthalmicequipment configured for use in an eye examination of a patient locatedat the diagnostic center, and an equipment controller configured toreceive instructions for controlling operation of the ophthalmicequipment from multiple remote locations during the eye examination; anda server system configured to exchange data communications through anumber of connections and perform operations comprising: assigning afirst connection through which communications are facilitated with acomputing device of a remote technician; assigning a second connectionthrough which communications are facilitated with a computing device ofa remote eyecare doctor; transmitting, over a network and to thecomputing device of the remote technician based on the first connection,data indicating permission being granted to the remote technician toadminister the eye examination from a first remote location bycontrolling the equipment controller to operate the ophthalmic equipmentduring a first portion of the eye examination; generating, based oninput data received from the computing device of the remote technician,examination data representing results of one or more tests administeredby the remote technician during the first portion of the eyeexamination; based on generation of the examination data: transmitting,over the network and to the computing device of the remote eyecaredoctor, data indicating permission being granted to the remote eyecaredoctor to: evaluate the examination data transmitted to a second remotelocation that is remote from the first remote location, and furtheradminister the eye examination from the second remote location bycontrolling the equipment controller based on input from the remoteeyecare doctor to operate the ophthalmic equipment during a secondportion of the eye examination; receiving, over the network and from thecomputing device of the remote eyecare doctor, evaluation datarepresenting an evaluation, by the remote eyecare doctor, of theexamination data representing results of the one or more testsadministered by the remote technician during the first portion of theeye examination; and providing, over the network, the evaluation datafor output.
 2. The system of claim 1, wherein: the diagnostic center islocated in a first geographic location; the first remote location islocated in a second geographic location; the second remote location islocated in a third geographic location; and the first geographiclocation, the second geographic location, and the third geographiclocation are each different geographic locations.
 3. The system of claim1, wherein the server system is configured to perform operationscomprising: receiving, over the network, patient data indicating (i)medical history information of the patient and (ii) result data of apre-refraction test performed on the patient at the diagnostic center bya local technician located at the diagnostic center; storing, within anelectronic record, the patient data and the examination datarepresenting one or more tests administered by the remote technicianduring the eye examination; and transmitting, over the network and tothe computing device of the remote eyecare doctor, data representing theelectronic record.
 4. The system of claim 1, wherein: the ophthalmicequipment comprises a phoropter located at the diagnostic center; thepermission granted to the remote technician comprises permission beinggranted to the remote technician to control the phoropter from the firstremote location; and the permission granted to the remote eyecare doctorcomprises permission being granted to the remote eyecare doctor tocontrol the phoropter from the second remote location.
 5. The system ofclaim 4, wherein: the remote eyecare doctor is granted permission tocontrol the phoropter from the second remote location after the remotetechnician is granted permission to control the phoropter from the firstremote location; and the remote eyecare doctor and the remote technicianare each granted permission to control the phoropter during the same eyeexamination.
 6. The system of claim 4, wherein: the remote eyecaredoctor is granted permission to control the phoropter from the secondremote location after the remote technician has completed administeringthe one or more tests during the first portion of the eye examination;and the remote eyecare doctor and the remote technician are each grantedpermission to control the phoropter during the same eye examination. 7.The system of claim 1, wherein the eye examination comprises at leastone of: a pinhole visual acuity test administered by the remotetechnician from the first remote location; a normal visual acuity testadministered by the remote technician from the first remote location; asubjective distance vision refraction test administered by the remotetechnician from the first remote location; a subjective near visionrefraction test administered by the remote technician from the firstremote location; and the server system is configured to transmit dataindicating permission being granted to the remote technician toadminister at least one of the pinhole visual acuity test, the normalvisual acuity test, and the subjective near vision refraction test. 8.The system of claim 1, wherein: the evaluation data indicates contactlens prescription for the patient based on results of the eyeexamination; and the diagnostic center is configured to provide anindication for the patient to try on a set of contact lensescorresponding to the contact lens prescription.
 9. The system of claim1, wherein the server system is further configured to perform operationscomprising: encrypting, based on applying a medical record protocol, theexamination data and the evaluation data; and storing the examinationdata and the evaluation data that have been encrypted based on applyingthe medical record protocol.
 10. The system of claim 1, whereinassigning the first connection comprises assigning a first connectionport through which communications are facilitated with the computingdevice of the remote technician.
 11. The system of claim 10, whereinassigning the second connection comprises assigning a second connectionport through which communications are facilitated with the computingdevice of the remote eyecare doctor.
 12. The system of claim 1, whereinthe server system is configured to perform operations comprising:receiving, over the network, a communication based on the firstconnection; determining whether an Internet Protocol (IP) addressspecified in the communication matches a verified IP addresscorresponding to the computing device of the remote technician; andtransmitting the data indicating permission being granted to the remotetechnician to administer the eye examination based on the determinationof whether the IP address specified in the communication matches theverified IP address corresponding to the computing device of the remotetechnician.
 13. The system of claim 12, wherein: determining whether theIP address specified in the communication matches the verified IPaddress corresponding to the computing device of the remote techniciancomprises determining that the IP address specified in the communicationmatches the verified IP address corresponding to the computing device ofthe remote technician; and transmitting the data indicating permissionbeing granted to the remote technician to administer the eye examinationbased on the determination that the IP address specified in thecommunication matches the verified IP address corresponding to thecomputing device of the remote technician.
 14. The system of claim 12,wherein: determining whether the IP address specified in thecommunication matches the verified IP address corresponding to thecomputing device of the remote technician comprises determining that theIP address specified in the communication does not match the verified IPaddress corresponding to the computing device of the remote technician;and terminating the first connection based on the determination that theIP address specified in the communication does not match the verified IPaddress corresponding to the computing device of the remote technician.15. A method performed by one or more computing devices, the methodcomprising: obtaining, from a diagnostic center, data indicating an eyeexamination of a patient located at the diagnostic center, wherein thediagnostic center includes: ophthalmic equipment configured for use inthe eye examination, and an equipment controller configured to receiveinstructions for controlling operation of the ophthalmic equipment frommultiple remote locations during the eye examination; assigning a firstconnection through which communications are facilitated with a computingdevice of a remote technician; assigning a second connection throughwhich communications are facilitated with a computing device of a remoteeyecare doctor; transmitting, over a network and to the computing deviceof the remote technician based on the first connection, data indicatingpermission being granted to the remote technician to administer the eyeexamination from a first remote location by controlling the equipmentcontroller to operate the ophthalmic equipment during a first portion ofthe eye examination; generating, based on input data received from thecomputing device of the remote technician, examination data representingresults of one or more tests administered by the remote technicianduring the first portion of the eye examination; based on generation ofthe examination data; transmitting, over the network and to thecomputing device of the remote eyecare doctor, data indicatingpermission being granted to the remote eyecare doctor to: evaluate theexamination data transmitted to a second remote location that is remotefrom the first remote location, and further administer the eyeexamination from the second remote location by controlling the equipmentcontroller based on input from the remote eyecare doctor to operate theophthalmic equipment during a second portion of the eye examination;receiving, over the network and from the computing device of the remoteeyecare doctor, evaluation data representing an evaluation, by theremote eyecare doctor, of the examination data representing results ofthe one or more tests administered by the remote technician during thefirst portion of the eye examination; and providing, over the network,the evaluation data for output.
 16. The method of claim 15, wherein: thediagnostic center is located in a first geographic location; the firstremote location is located in a second geographic location; the secondremote location is located in a third geographic location; and the firstgeographic location, the second geographic location, and the thirdgeographic location are each different geographic locations.
 17. Themethod of claim 15, further comprising: receiving, over the network,patient data indicating (i) medical history information of the patientand (ii) result data of a pre-refraction test performed on the patientat the diagnostic center by a local technician located at the diagnosticcenter; storing, within an electronic record, the patient data and theexamination data representing one or more tests administered by theremote technician during the eye examination; and transmitting, over thenetwork and to the computing device of the remote eyecare doctor, datarepresenting the electronic record.
 18. A system for facilitatingcomprehensive eye examinations, comprising: a diagnostic centerincluding: equipment means for conducting an eye examination of apatient located at the diagnostic center, and a controller means forreceiving instructions for controlling operation of the equipment meansfrom multiple remote locations during the eye examination; and a servermeans for exchanging data communications through a number of connectionsand performing operations comprising: assigning a first connectionthrough which communications are facilitated with a computing device ofa remote technician; assigning a second connection through whichcommunications are facilitated with a computing device of a remoteeyecare doctor; transmitting, over a network and to the computing deviceof the remote technician based on the first connection, data indicatingpermission being granted to the remote technician to administer the eyeexamination from a first remote location by controlling the controllermeans to operate the equipment means during a first portion of the eyeexamination; generating, based on input data received from the computingdevice of the remote technician, examination data representing resultsof one or more tests administered by the remote technician during thefirst portion of the eye examination; based on generation of theexamination data: transmitting, over the network and to the computingdevice of the remote eyecare doctor, data indicating permission beinggranted to the remote eyecare doctor to: evaluate the examination datatransmitted to a second remote location that is remote from the firstremote location, and further administer the eye examination from thesecond remote location by controlling the controller means based oninput from the remote eyecare doctor to operate the equipment meansduring a second portion of the eye examination; receiving, over thenetwork and from the computing device of the remote eyecare doctor,evaluation data representing an evaluation, by the remote eyecaredoctor, of the examination data representing results of the one or moretests administered by the remote technician during the first portion ofthe eye examination; and providing, over the network, the evaluationdata for output.
 19. The system of claim 18, wherein: the diagnosticcenter is located in a first geographic location; the first remotelocation is located in a second geographic location; the second remotelocation is located in a third geographic location; and the firstgeographic location, the second geographic location, and the thirdgeographic location are each different geographic locations.
 20. Thesystem of claim 18, wherein the server means is configured to performoperations comprising: receiving, over the network, patient dataindicating (i) medical history information of the patient and (ii)result data of a pre-refraction test performed on the patient at thediagnostic center by a local technician located at the diagnosticcenter; storing, within an electronic record, the patient data and theexamination data representing one or more tests administered by theremote technician during the eye examination; and transmitting, over thenetwork and to the computing device of the remote eyecare doctor, datarepresenting the electronic record.